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Bellido V, Freckman G, Pérez A, Galindo RJ. Accuracy and Potential Interferences of Continuous Glucose Monitoring Sensors in the Hospital. Endocr Pract 2023; 29:919-927. [PMID: 37369291 DOI: 10.1016/j.eprac.2023.06.007] [Citation(s) in RCA: 1] [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: 04/10/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
For years, the standard of care for monitoring dysglycemia in hospitalized patients was capillary blood glucose (CBG) testing with point-of-care glucose meters. Recently, there has been a revolution in novel factory-calibrated continuous glucose monitoring (CGM) systems. Newer CGMs are smaller and less expensive, have improved accuracy and longer wear time, and do not require fingerstick CBG for calibration, resulting in increased utilization in ambulatory settings. Consequently, hospitals have noticed increased usability of CGMs among hospitalized patients and expect a progressive continued increase. During the COVID-19 pandemic, there was a critical need for innovative approaches to glycemic monitoring, with several pilot implementation projects using CGM in the intensive care unit and non-intensive care unit settings, further boosting the evidence in this area. Hence, recent guidelines have provided recommendations for the use of CGM in specific hospital scenarios and highlighted the potential of CGM to overcome CBG limitations for glucose monitoring in the inpatient setting. In this review, we provide the following: 1) an up-to-date review of the accuracy of the newer CGMs in hospitalized patients, 2) a discussion of standards for CGM accuracy metrics, 3) a contemporary overview of potential interferences that may cause inaccuracies or poor CGM performance, and 4) required steps for full regulatory approval of CGMs in the hospital and future research steps to advance the field forward.
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Affiliation(s)
- Virginia Bellido
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Guido Freckman
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Antonio Pérez
- Servicio de Endocrinología y Nutrición. Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Universitat Autònoma de Barcelona. CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, España
| | - Rodolfo J Galindo
- University of Miami Miller School of Medicine, Division of Endocrinology, Diabetes and Metabolism, Miami, Florida.
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2
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Buschur EO, Faulds E, Dungan K. CGM in the Hospital: Is It Ready for Prime Time? Curr Diab Rep 2022; 22:451-460. [PMID: 35796882 PMCID: PMC9261155 DOI: 10.1007/s11892-022-01484-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The use of continuous glucose monitoring (CGM) in the hospital setting is growing with more patients using these devices at home and when admitted to the hospital, especially during the COVID-19 pandemic. RECENT FINDINGS Historically, most evidence for CGM use in the inpatient setting was limited to small studies utilizing outdated CGM technology and analyzing accuracy of sensor measurements. Previous studies have shown reduced sensor accuracy during extreme hypo- or hyperglycemia, rapid fluctuations of glucose, compression of the sensor itself, and in those who are critically ill. Studies that are more recent have shown CGM to have adequate accuracy and may be effective in reducing hypoglycemia in hospitalized patients; some studies have also showed improvement in time in target glycemic range. Furthermore, CGM may reduce nursing workload, cost of inpatient care, and use of personal protective equipment and face-to-face patient care especially for patients during the COVID-19 pandemic. This review will describe the evidence for use of CGM in hospitalized critically ill or non-critically ill patients, address accuracy and safety considerations, and outline paths for future implementation.
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Affiliation(s)
- Elizabeth O. Buschur
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
| | - Eileen Faulds
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
- grid.261331.40000 0001 2285 7943The Ohio State University College of Nursing, Columbus, OH USA
| | - Kathleen Dungan
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
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3
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Perez-Guzman MC, Shang T, Zhang JY, Jornsay D, Klonoff DC. Continuous Glucose Monitoring in the Hospital. Endocrinol Metab (Seoul) 2021; 36:240-255. [PMID: 33789033 PMCID: PMC8090458 DOI: 10.3803/enm.2021.201] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 12/14/2022] Open
Abstract
Continuous glucose monitors (CGMs) have suddenly become part of routine care in many hospitals. The coronavirus disease 2019 (COVID-19) pandemic has necessitated the use of new technologies and new processes to care for hospitalized patients, including diabetes patients. The use of CGMs to automatically and remotely supplement or replace assisted monitoring of blood glucose by bedside nurses can decrease: the amount of necessary nursing exposure to COVID-19 patients with diabetes; the amount of time required for obtaining blood glucose measurements, and the amount of personal protective equipment necessary for interacting with patients during the blood glucose testing. The United States Food and Drug Administration (FDA) is now exercising enforcement discretion and not objecting to certain factory-calibrated CGMs being used in a hospital setting, both to facilitate patient care and to obtain performance data that can be used for future regulatory submissions. CGMs can be used in the hospital to decrease the frequency of fingerstick point of care capillary blood glucose testing, decrease hyperglycemic episodes, and decrease hypoglycemic episodes. Most of the research on CGMs in the hospital has focused on their accuracy and only recently outcomes data has been reported. A hospital CGM program requires cooperation of physicians, bedside nurses, diabetes educators, and hospital administrators to appropriately select and manage patients. Processes for collecting, reviewing, storing, and responding to CGM data must be established for such a program to be successful. CGM technology is advancing and we expect that CGMs will be increasingly used in the hospital for patients with diabetes.
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Affiliation(s)
- M. Citlalli Perez-Guzman
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University, Atlanta, GA,
USA
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA,
USA
| | | | - Donna Jornsay
- Diabetes Program, Mills-Peninsula Medical Center, Burlingame, CA,
USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA,
USA
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4
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Bochicchio GV, Nasraway SA, Moore LJ, Furnary AP, Nohra EA, Bochicchio KM, Boyd JC, Bruns DI, Hirsch IB, Preiser JC, Krinsley JS. Fifteen-minute Frequency of Glucose Measurements and the Use of Threshold Alarms: Impact on Mitigating Dysglycemia in Critically Ill Patients. J Diabetes Sci Technol 2021; 15:279-286. [PMID: 31744315 PMCID: PMC8256060 DOI: 10.1177/1932296819886917] [Citation(s) in RCA: 3] [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] [Indexed: 12/24/2022]
Abstract
BACKGROUND The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients. METHODS An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%. RESULTS At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial. CONCLUSION Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.
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Affiliation(s)
| | | | - Laura J. Moore
- Department of Surgery, University of
Texas, McGovern Medical School, Houston, TX, USA
- Memorial Hermann Hospital, Houston, TX,
USA
| | - Anthony P. Furnary
- Providence St Vincent Medical Center,
Portland, OR, USA
- Oregon Med Laser Center, Portland, OR,
USA
- Portland Diabetes Project, OR, USA
| | - Eden A. Nohra
- Washington University, St. Louis School
of Medicine, MO, USA
| | | | - James C. Boyd
- University of Virginia Health System,
Charlottesville, VA, USA
| | - David I. Bruns
- University of Virginia Health System,
Charlottesville, VA, USA
| | - Irl B. Hirsch
- University of Washington School of
Medicine, Seattle, WA, USA
| | | | - James S. Krinsley
- Division of Critical Care, Stamford
Hospital and Columbia Vagelos College of Physicians and Surgeons, CT, USA
- James S. Krinsley, MD, FCCM, FCCP, Columbia
Vagelos College of Physicians and Surgeons, Division of Critical Care,
Department of Medicine, Stamford Hospital, 1 Hospital Plaza, Stamford, CT 06902,
USA.
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5
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Galindo RJ, Aleppo G. Continuous glucose monitoring: The achievement of 100 years of innovation in diabetes technology. Diabetes Res Clin Pract 2020; 170:108502. [PMID: 33065179 PMCID: PMC7736459 DOI: 10.1016/j.diabres.2020.108502] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Monitoring of glucose levels is essential to effective diabetes management. Over the past 100 years, there have been numerous innovations in glucose monitoring methods. The most recent advances have centered on continuous glucose monitoring (CGM) technologies. Numerous studies have demonstrated that use of continuous glucose monitoring confers significant glycemic benefits on individuals with type 1 diabetes (T1DM) and type 2 diabetes (T2DM). Ongoing improvements in accuracy and convenience of CGM devices have prompted increasing adoption of this technology. The development of standardized metrics for assessing CGM data has greatly improved and streamlined analysis and interpretation, enabling clinicians and patients to make more informed therapy modifications. However, many clinicians many be unfamiliar with current CGM and how use of these devices may help individuals with T1DM and T2DM achieve their glycemic targets. The purpose of this review is to present an overview of current CGM systems and provide guidance to clinicians for initiating and utilizing CGM in their practice settings.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Dr., Glenn Building, Suite 202, Atlanta, GA, 30303, USA.
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 530, Chicago, IL 60611, USA.
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6
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Galindo RJ, Umpierrez GE, Rushakoff RJ, Basu A, Lohnes S, Nichols JH, Spanakis EK, Espinoza J, Palermo NE, Awadjie DG, Bak L, Buckingham B, Cook CB, Freckmann G, Heinemann L, Hovorka R, Mathioudakis N, Newman T, O’Neal DN, Rickert M, Sacks DB, Seley JJ, Wallia A, Shang T, Zhang JY, Han J, Klonoff DC. Continuous Glucose Monitors and Automated Insulin Dosing Systems in the Hospital Consensus Guideline. J Diabetes Sci Technol 2020; 14:1035-1064. [PMID: 32985262 PMCID: PMC7645140 DOI: 10.1177/1932296820954163] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article is the work product of the Continuous Glucose Monitor and Automated Insulin Dosing Systems in the Hospital Consensus Guideline Panel, which was organized by Diabetes Technology Society and met virtually on April 23, 2020. The guideline panel consisted of 24 international experts in the use of continuous glucose monitors (CGMs) and automated insulin dosing (AID) systems representing adult endocrinology, pediatric endocrinology, obstetrics and gynecology, advanced practice nursing, diabetes care and education, clinical chemistry, bioengineering, and product liability law. The panelists reviewed the medical literature pertaining to five topics: (1) continuation of home CGMs after hospitalization, (2) initiation of CGMs in the hospital, (3) continuation of AID systems in the hospital, (4) logistics and hands-on care of hospitalized patients using CGMs and AID systems, and (5) data management of CGMs and AID systems in the hospital. The panelists then developed three types of recommendations for each topic, including clinical practice (to use the technology optimally), research (to improve the safety and effectiveness of the technology), and hospital policies (to build an environment for facilitating use of these devices) for each of the five topics. The panelists voted on 78 proposed recommendations. Based on the panel vote, 77 recommendations were classified as either strong or mild. One recommendation failed to reach consensus. Additional research is needed on CGMs and AID systems in the hospital setting regarding device accuracy, practices for deployment, data management, and achievable outcomes. This guideline is intended to support these technologies for the management of hospitalized patients with diabetes.
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Affiliation(s)
| | | | | | - Ananda Basu
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Suzanne Lohnes
- University of California San Diego Medical Center, La Jolla, CA, USA
| | | | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, MD, USA
| | | | - Nadine E. Palermo
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Tonya Newman
- Neal, Gerber and Eisenberg LLP, Chicago, IL, USA
| | - David N. O’Neal
- University of Melbourne Department of Medicine, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| | | | | | | | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | | | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive Room 5147, San Mateo, CA 94401, USA.
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7
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Avari P, Reddy M, Oliver N. Is it possible to constantly and accurately monitor blood sugar levels, in people with Type 1 diabetes, with a discrete device (non-invasive or invasive)? Diabet Med 2020; 37:532-544. [PMID: 30803028 DOI: 10.1111/dme.13942] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2019] [Indexed: 12/15/2022]
Abstract
Real-time continuous glucose monitors using subcutaneous needle-type sensors continue to develop. The limitations of currently available systems, however, include time lag behind changes in blood glucose, the invasive nature of such systems, and in some cases, their accuracy. Non-invasive techniques have been developed, but, to date, no commercial device has been successful. A key research priority for people with Type 1 diabetes identified by the James Lind Alliance was to identify ways of monitoring blood glucose constantly and accurately using a discrete device, invasive or non-invasive. Integration of such a sensor is important in the development of a closed-loop system and the technology must be rapid, selective and acceptable for continuous use by individuals. The present review provides an update on existing continuous glucose-sensing technologies, and an overview of emergent techniques, including their accuracy and limitations.
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Affiliation(s)
- P Avari
- Division of Diabetes, Endocrinology and Metabolism, Faculty of Medicine, Imperial College, London, UK
| | - M Reddy
- Division of Diabetes, Endocrinology and Metabolism, Faculty of Medicine, Imperial College, London, UK
| | - N Oliver
- Division of Diabetes, Endocrinology and Metabolism, Faculty of Medicine, Imperial College, London, UK
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8
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DeJournett J, Nekludov M, DeJournett L, Wallin M. Performance of a closed-loop glucose control system, comprising a continuous glucose monitoring system and an AI-based controller in swine during severe hypo- and hyperglycemic provocations. J Clin Monit Comput 2020; 35:317-325. [PMID: 32006145 PMCID: PMC7943496 DOI: 10.1007/s10877-020-00474-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/24/2020] [Indexed: 01/04/2023]
Abstract
Intensive care unit (ICU) patients develop stress induced insulin resistance causing hyperglycemia, large glucose variability and hypoglycemia. These glucose metrics have all been associated with increased rates of morbidity and mortality. The only way to achieve safe glucose control at a lower glucose range (e.g., 4.4–6.6 mmol/L) will be through use of an autonomous closed loop glucose control system (artificial pancreas). Our goal with the present study was to assess the safety and performance of an artificial pancreas system, composed of the EIRUS (Maquet Critical Care AB) continuous glucose monitor (CGM) and novel artificial intelligence-based glucose control software, in a swine model using unannounced hypo- and hyperglycemia challenges. Fourteen piglets (6 control, 8 treated) underwent sequential unannounced hypoglycemic and hyperglycemic challenges with 3 IU of NovoRapid and a glucose infusion at 17 mg/kg/min over the course of 5 h. In the Control animals an experienced ICU physician used every 30-min blood glucose values to maintain control to a range of 4.4–9 mmol/L. In the Treated group the artificial pancreas system attempted to maintain blood glucose control to a range of 4.4–6.6 mmol/L. Five of six Control animals and none of eight Treated animals experienced severe hypoglycemia (< 2.22 mmol/L). The area under the curve 3.5 mmol/L was 28.9 (21.1–54.2) for Control and 4.8 (3.1–5.2) for the Treated animals. The total percent time within tight glucose control range, 4.4–6.6 mmol/L, was 32.8% (32.4–47.1) for Controls and 55.4% (52.9–59.4) for Treated (p < 0.034). Data are median and quartiles. The artificial pancreas system abolished severe hypoglycemia and outperformed the experienced ICU physician in avoiding clinically significant hypoglycemic excursions.
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Affiliation(s)
- Jeremy DeJournett
- Ideal Medical Technologies, 18 N Kensington Rd, Asheville, NC 28804 USA
| | - Michael Nekludov
- Karolinska University Hospital, Karolinska Universitetssjukhuset, Eugeniavägen 3, 171 76 Solna, Sweden
| | - Leon DeJournett
- Ideal Medical Technologies, 18 N Kensington Rd, Asheville, NC 28804 USA
| | - Mats Wallin
- Maquet Critical Care AB, Röntgenvägen 2, 17154 Solna, Sweden
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9
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Smith AF, Shinkins B, Hall PS, Hulme CT, Messenger MP. Toward a Framework for Outcome-Based Analytical Performance Specifications: A Methodology Review of Indirect Methods for Evaluating the Impact of Measurement Uncertainty on Clinical Outcomes. Clin Chem 2019; 65:1363-1374. [PMID: 31444309 PMCID: PMC7055686 DOI: 10.1373/clinchem.2018.300954] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 06/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND For medical tests that have a central role in clinical decision-making, current guidelines advocate outcome-based analytical performance specifications. Given that empirical (clinical trial-style) analyses are often impractical or unfeasible in this context, the ability to set such specifications is expected to rely on indirect studies to calculate the impact of test measurement uncertainty on downstream clinical, operational, and economic outcomes. Currently, however, a lack of awareness and guidance concerning available alternative indirect methods is limiting the production of outcome-based specifications. Therefore, our aim was to review available indirect methods and present an analytical framework to inform future outcome-based performance goals. CONTENT A methodology review consisting of database searches and extensive citation tracking was conducted to identify studies using indirect methods to incorporate or evaluate the impact of test measurement uncertainty on downstream outcomes (including clinical accuracy, clinical utility, and/or costs). Eighty-two studies were identified, most of which evaluated the impact of imprecision and/or bias on clinical accuracy. A common analytical framework underpinning the various methods was identified, consisting of 3 key steps: (a) calculation of "true" test values; (b) calculation of measured test values (incorporating uncertainty); and (c) calculation of the impact of discrepancies between (a) and (b) on specified outcomes. A summary of the methods adopted is provided, and key considerations are discussed. CONCLUSIONS Various approaches are available for conducting indirect assessments to inform outcome-based performance specifications. This study provides an overview of methods and key considerations to inform future studies and research in this area.
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Affiliation(s)
- Alison F Smith
- Test Evaluation Group, Academic Unit of Health Economics, University of Leeds, Leeds, UK;
- NIHR Leeds In Vitro Diagnostic (IVD) Co-operative, Leeds, UK
| | - Bethany Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, University of Leeds, Leeds, UK
- NIHR Leeds In Vitro Diagnostic (IVD) Co-operative, Leeds, UK
- CanTest Collaborative, UK
| | - Peter S Hall
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Claire T Hulme
- Test Evaluation Group, Academic Unit of Health Economics, University of Leeds, Leeds, UK
- Health Economics Group, University of Exeter, Exeter, UK
| | - Mike P Messenger
- NIHR Leeds In Vitro Diagnostic (IVD) Co-operative, Leeds, UK
- CanTest Collaborative, UK
- Leeds Centre for Personalised Medicine and Health, University of Leeds, Leeds, UK
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10
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Abstract
OBJECTIVES Tight glycemic control using intermittent blood glucose measurements is associated with a risk of hypoglycemia. Glucose concentrations can now be measured near continuously (every 5-15 min). We assessed the quality and safety of glycemic control guided by a near-continuous glucose monitoring system in ICU patients. DESIGN Prospective, cluster-randomized, crossover study. SETTING Thirty-five-bed medico-surgical department of intensive care with four separate ICUs. PATIENTS Adult patients admitted to the department and expected to stay for at least 3 days were considered for inclusion if they had persistent hyperglycemia (blood glucose > 150 mg/dL) up to 6 hours after admission and/or were receiving insulin therapy. INTERVENTIONS A peripheral venous catheter was inserted in all patients and connected to a continuous glucose monitoring sensor (GlucoClear; Edwards Lifesciences, Irvine, CA). The four ICUs were randomized in pairs in a crossover design to glycemic control using unblinded or blinded continuous glucose monitoring monitors. The insulin infusion rate was adjusted to keep blood glucose between 90 and 150 mg/dL using the blood glucose values displayed on the continuous glucose monitor (continuous glucose monitoring group-unblinded units) or according to intermittent blood glucose readings (intermittent glucose monitoring group-blinded units). MEASUREMENTS AND MAIN RESULTS The quality and safety of glycemic control were assessed using the proportion of time in range, the frequency of blood glucose less than 70 mg/dL, and the time spent with blood glucose less than 70 mg/dL (TB70), using blood glucose values measured by the continuous glucose monitoring device. Seventy-seven patients were enrolled: 39 in the continuous glucose monitoring group and 38 in the intermittent glucose monitoring group. A total of 43,107 blood glucose values were recorded. The time in range was similar in the two groups. The incidence of hypoglycemia (8/39 [20.5%] vs 15/38 [39.5%]) and the TB70 (0.4% ± 0.9% vs 1.6% ± 3.4%; p < 0.05) was lower in the continuous glucose monitoring than in the intermittent glucose monitoring group. CONCLUSIONS Use of a continuous glucose monitoring-based strategy decreased the incidence and severity of hypoglycemia, thus improving the safety of glycemic control.
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11
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Abstract
Hyperglycemia is common in the intensive care unit (ICU) both in patients with and without a previous diagnosis of diabetes. The optimal glucose range in the ICU population is still a matter of debate. Given the risk of hypoglycemia associated with intensive insulin therapy, current recommendations include treating hyperglycemia after two consecutive glucose >180 mg/dL with target levels of 140-180 mg/dL for most patients. The optimal method of sampling glucose and delivery of insulin in critically ill patients remains elusive. While point of care glucose meters are not consistently accurate and have to be used with caution, continuous glucose monitoring (CGM) is not standard of care, nor is it generally recommended for inpatient use. Intravenous insulin therapy using paper or electronic protocols remains the preferred approach for critically ill patients. The advent of new technologies, such as electronic glucose management, CGM, and closed-loop systems, promises to improve inpatient glycemic control in the critically ill with lower rates of hypoglycemia.
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Affiliation(s)
- Pedro D. Salinas
- Aurora Critical Care Services,
University of Wisconsin School of Medicine and Public Health, Milwaukee, WI,
USA
- Pedro D. Salinas, MD, FCCP, Aurora Critical
Care Service, University of Wisconsin School of Medicine and Public Health, 2901
W Kinnickinnic River Pkwy, Ste 305, Milwaukee, WI 53215-3268, USA.
| | - Carlos E. Mendez
- Froedtert and Medical College of
Wisconsin, Division of Diabetes and Endocrinology, Zablocki Veteran Affairs Medical
Center, Milwaukee, WI, USA
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12
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Satyarengga M, Siddiqui T, Spanakis EK. Designing the Glucose Telemetry for Hospital Management: From Bedside to the Nursing Station. Curr Diab Rep 2018; 18:87. [PMID: 30159754 DOI: 10.1007/s11892-018-1067-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF THE REVIEW Hospitalized patients with diabetes are monitored with point-of-care glucose testing. Continuous glucose monitoring (CGM) devices represent an alternative way to monitor glucose values; however, the in-hospital CGM use is still considered experimental. Most inpatient studies used "blinded" CGM properties and only few used the real-time/unblinded CGM features. One major limitation of the CGM devices is that they need to be placed at the patients' bedside, limiting any therapeutic interventions. In this article, we review the real-time/unblinded CGM use and share our thoughts about the development of future inpatient CGM systems. RECENT FINDINGS We recently reported that glucose values can be wirelessly transmitted to the nursing station, providing remote continuous glucose monitoring. Future inpatient CGM devices may be utilized for patients at risk for hypoglycemia similarly to the way that we use cardiac telemetry to monitor hospitalized patients who are at increased risk for cardiac arrhythmias.
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Affiliation(s)
- Medha Satyarengga
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, 827 Linden Avenue, Baltimore, MD, 21201, USA
| | - Tariq Siddiqui
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, 827 Linden Avenue, Baltimore, MD, 21201, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, 10 N. Greene Street, Baltimore, MD, 21201, USA
| | - Elias K Spanakis
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, 827 Linden Avenue, Baltimore, MD, 21201, USA.
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, 10 N. Greene Street, Baltimore, MD, 21201, USA.
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13
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Umpierrez GE, Klonoff DC. Diabetes Technology Update: Use of Insulin Pumps and Continuous Glucose Monitoring in the Hospital. Diabetes Care 2018; 41:1579-1589. [PMID: 29936424 PMCID: PMC6054505 DOI: 10.2337/dci18-0002] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/20/2018] [Indexed: 02/03/2023]
Abstract
The use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems has gained wide acceptance in diabetes care. These devices have been demonstrated to be clinically valuable, improving glycemic control and reducing risks of hypoglycemia in ambulatory patients with type 1 diabetes and type 2 diabetes. Approximately 30-40% of patients with type 1 diabetes and an increasing number of insulin-requiring patients with type 2 diabetes are using pump and sensor technology. As the popularity of these devices increases, it becomes very likely that hospital health care providers will face the need to manage the inpatient care of patients under insulin pump therapy and CGM. The American Diabetes Association advocates allowing patients who are physically and mentally able to continue to use their pumps when hospitalized. Health care institutions must have clear policies and procedures to allow the patient to continue to receive CSII treatment to maximize safety and to comply with existing regulations related to self-management of medication. Randomized controlled trials are needed to determine whether CSII therapy and CGM systems in the hospital are associated with improved clinical outcomes compared with intermittent monitoring and conventional insulin treatment or with a favorable cost-benefit ratio.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
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14
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Dickerson RN, Kumpf VJ, Bingham AL, Blackmer AB, Canada TW, Chan LN, Cogle SV, Tucker AM. Significant Published Articles for Pharmacy Nutrition Support Practice in 2017. Hosp Pharm 2018; 53:239-246. [PMID: 30038443 PMCID: PMC6050880 DOI: 10.1177/0018578718779006] [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] [Indexed: 12/17/2022]
Abstract
Purpose: The purpose of the article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2017 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority (at least 5 out of 8 authors) considered the article to be of significance. Guideline and consensus articles from professional organizations, important to practice but not scored, were also included. Results: A total of 95 articles were identified; six from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | | | - Todd W. Canada
- University of Texas MD Anderson Cancer
Center, Houston, USA
| | | | | | - Anne M. Tucker
- University of Texas MD Anderson Cancer
Center, Houston, USA
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15
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Zhou T, Dickson JL, Shaw GM, Chase JG. Continuous Glucose Monitoring Measures Can Be Used for Glycemic Control in the ICU: An In-Silico Study. J Diabetes Sci Technol 2018; 12:7-19. [PMID: 29103302 PMCID: PMC5761989 DOI: 10.1177/1932296817738791] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) technology has become more prevalent in the intensive care unit (ICU), offering potential benefits of increased safety and reduced workload in glycemic control (GC). The drift and higher point accuracy errors of CGM devices over traditional intermittent blood glucose (BG) measures have so far limited their application in the ICU. This study delineates the trade-offs of performance, safety and workload that CGM sensors provide in GC protocols. METHODS Clinical data from 236 patients were used for clinically validated virtual trials. A CGM-enabled version of the STAR GC protocol was used to evaluate the use of guard rails and rolling windows. Safety was assessed through percentage of patients who had a severe hypoglycemic episode (BG < 40 mg/dl) as well as percentage of resampled BG < 72 mg/dl. Performance was assessed as percentage of resampled measurements in the 80-126 mg/dl and the 80-144 mg/dl target bands. Workload was measured by number of manual BG measures per day. RESULTS CGM-enabled versions of STAR decreased the number of required blood draws by up to 74%, while maintaining performance (76.6% BG measurements in the 80-126 mg/dl range vs 62.8% clinically, 87.9% in the 80-144 mg/dl range vs 83.7% clinically) and maintaining patient safety (1.13% of patients experienced a severe hypoglycemic event vs 0.85% clinically, 1.37% of BG measurements were less than 72 mg/dl vs 0.51% clinically). CONCLUSION CGM sensor traces were reproduced in virtual trials to guide GC. Existing GC protocols such as STAR may need to be adjusted only slightly to gain the benefits of the increased temporal measurements of CGM sensors, through which workload may be significantly decreased while maintaining GC performance and safety.
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Affiliation(s)
- Tony Zhou
- Department of Mechanical Engineering, University of Canterbury, Christchurch, Canterbury, New Zealand
- Tony Zhou, BE, Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Riccarton, Christchurch, Canterbury 8041, New Zealand.
| | - Jennifer L. Dickson
- Department of Mechanical Engineering, University of Canterbury, Christchurch, Canterbury, New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch School of Medicine and Health Science, University of Otago, New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, Canterbury, New Zealand
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16
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Krinsley JS, Chase JG, Gunst J, Martensson J, Schultz MJ, Taccone FS, Wernerman J, Bohe J, De Block C, Desaive T, Kalfon P, Preiser JC. Continuous glucose monitoring in the ICU: clinical considerations and consensus. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:197. [PMID: 28756769 PMCID: PMC5535285 DOI: 10.1186/s13054-017-1784-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Glucose management in intensive care unit (ICU) patients has been a matter of debate for almost two decades. Compared to intermittent monitoring systems, continuous glucose monitoring (CGM) can offer benefit in the prevention of severe hyperglycemia and hypoglycemia by enabling insulin infusions to be adjusted more rapidly and potentially more accurately because trends in glucose concentrations can be more readily identified. Increasingly, it is apparent that a single glucose target/range may not be optimal for all patients at all times and, as with many other aspects of critical care patient management, a personalized approach to glucose control may be more appropriate. Here we consider some of the evidence supporting different glucose targets in various groups of patients, focusing on those with and without diabetes and neurological ICU patients. We also discuss some of the reasons why, despite evidence of benefit, CGM devices are still not widely employed in the ICU and propose areas of research needed to help move CGM from the research arena to routine clinical use.
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Affiliation(s)
- James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, 06902, USA
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, 8140, New Zealand
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000, Leuven, Belgium
| | - Johan Martensson
- Department of Intensive Care, Austin Hospital, Heidelberg, 3084, VIC, Australia.,Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Marcus J Schultz
- Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesia (L E I C A), Faculty of Tropical Medicine, Mahidol University, Mahidol-Oxford Research Unit (MORU), Bangkok, Thailand
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
| | - Jan Wernerman
- Karolinska University Hospital Huddinge & Karolinska Institutet, K32 14186, Stockholm, Sweden
| | - Julien Bohe
- Medical Intensive Care Unit, University Hospital of Lyon, Lyon, France
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, B-2650, Edegem, Belgium
| | - Thomas Desaive
- GIGA-In Silico Medicine, Université de Liège, B4000, Liège, Belgium
| | - Pierre Kalfon
- Service de Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, 28000, Chartres, France
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium.
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