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Khan SA, Demidowich AP, Tschudy MM, Wedler J, Lamy W, Akpandak I, Alexander LA, Misra I, Sidhaye A, Rotello L, Zilbermint M. Increasing Frequency of Hemoglobin A1c Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma. J Diabetes Sci Technol 2024; 18:866-873. [PMID: 36788726 PMCID: PMC11307218 DOI: 10.1177/19322968231153883] [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] [Indexed: 02/16/2023]
Abstract
BACKGROUND The American Diabetes Association (ADA) recommends measuring A1c in all inpatients with diabetes if not performed in the prior three months. Our objective was to determine the impact of utilizing Lean Six Sigma to increase the frequency of A1c measurements in hospitalized patients. METHODS We evaluated inpatients with diabetes mellitus consecutively admitted in a community hospital between January 2016 and June 2021, excluding those who had an A1c in the electronic health record (EHR) in the previous three months. Lean Six Sigma was utilized to define the extent of the problem and devise solutions. The intervention bundle delivered between November 2017 and February 2018 included (1) provider education on the utility of A1c, (2) more rapid turnaround of A1c results, and (3) an EHR glucose-management tab and insulin order set that included A1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Frequency of A1c measurement was compared before (January 2016-November 2017) and after the intervention (March 2018-June 2021) using χ2 analysis. RESULTS Demographics did not differ preintervention versus postintervention (mean age [range]: 70.9 [18-104] years, sex: 52.2% male, race: 57.0% white). A1c measurements significantly increased following implementation of the intervention bundle (61.2% vs 74.5%, P < .001). This level was sustained for more than two years following the initial intervention. Patients seen by the diabetes consult service (40.4% vs 51.7%, P < 0.001) and length of stay (mean: 135 hours vs 149 hours, P < 0.001) both increased postintervention. CONCLUSIONS We demonstrate a novel approach in improving A1c in hospitalized patients. Lean Six Sigma may represent a valuable methodology for community hospitals to improve inpatient diabetes care.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew P. Demidowich
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan M. Tschudy
- Division of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joyce Wedler
- Department of Information Systems, Suburban Hospital, Bethesda, MD, USA
| | - Wilson Lamy
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iniuboho Akpandak
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Lee Ann Alexander
- Department of Pharmacy, Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD, USA
| | - Isha Misra
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leo Rotello
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
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Mehta PB, Kohn MA, Rov-Ikpah E, San Luis C, Johnson C, Lee G, Koliwad S, Rushakoff RJ. Novel Automated Self-adjusting Subcutaneous Insulin Algorithm Improves Glycemic Control and Physician Efficiency in Hospitalized Patients. J Diabetes Sci Technol 2024; 18:541-548. [PMID: 38454631 PMCID: PMC11089873 DOI: 10.1177/19322968241232673] [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] [Indexed: 03/09/2024]
Abstract
BACKGROUND Hyperglycemia occurs in 22% to 46% of hospitalized patients, negatively affecting patient outcomes, including mortality, inpatient complications, length of stay, and hospital costs. Achieving inpatient glycemic control is challenging due to inconsistent caloric intake, changes from home medications, a catabolic state in the setting of acute illness, consequences of acute inflammation, intercurrent infection, and limitations in labor-intensive glucose monitoring and insulin administration. METHOD We conducted a retrospective cross-sectional analysis at the University of California San Francisco hospitals between September 3, 2020 and September 2, 2021, comparing point-of-care glucose measurements in patients on nil per os (NPO), continuous total parenteral nutrition, or continuous tube feeding assigned to our novel automated self-adjusting subcutaneous insulin algorithm (SQIA) or conventional, physician-driven insulin dosing. We also evaluated physician efficiency by tracking the number of insulin orders placed or modified. RESULTS The proportion of glucose in range (70-180 mg/dL) was higher in the SQIA group than in the conventional group (71.0% vs 69.0%, P = .153). The SQIA led to a lower proportion of severe hyperglycemia (>250 mg/dL; 5.8% vs 7.2%, P = .017), hypoglycemia (54-69 mg/dL; 0.8% vs 1.2%, P = .029), and severe hypoglycemia (<54 mg/dL; 0.3% vs 0.5%, P = .076) events. The number of orders a physician had to place while a patient was on the SQIA was reduced by a factor of more than 12, when compared with while a patient was on conventional insulin dosing. CONCLUSIONS The SQIA reduced severe hyperglycemia, hypoglycemia, and severe hypoglycemia compared with conventional insulin dosing. It also improved physician efficiency by reducing the number of order modifications a physician had to place.
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Affiliation(s)
- Paras B Mehta
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
| | - Michael A Kohn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Esther Rov-Ikpah
- Institute of Nursing Excellence, University of California, San Francisco, CA, USA
| | - Craig San Luis
- Department of Clinical Systems, University of California, San Francisco, CA, USA
| | - Craig Johnson
- Department of Health Informatics, University of California, San Francisco, CA, USA
| | - Gwendolyn Lee
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Suneil Koliwad
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
| | - Robert J Rushakoff
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
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Shabnam S, Abner S, Gillies CL, Davies MJ, Dex T, Khunti K, Webb DR, Zaccardi F, Seidu S. Effect of delay in treatment intensification in people with type 2 diabetes and suboptimal glycaemia after basal insulin initiation: A real-world observational study. Diabetes Obes Metab 2024; 26:512-523. [PMID: 37857573 DOI: 10.1111/dom.15337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
AIM Despite global recommendations for type 2 diabetes mellitus treatment to maintain optimal glycaemic targets, a significant proportion of people remain in suboptimal glycaemic control. Our objective was to investigate the impact of intensification delay after basal insulin (BI) initiation on long-term complications in people with suboptimal glycaemia. MATERIALS AND METHODS We conducted a retrospective cohort study in individuals with type 2 diabetes mellitus initiated on BI. Those with suboptimal glycaemia (glycated haemoglobin ≥7% or ≥53 mmol/mol) within 12 months of BI initiation were divided into early (treatment intensified within 5 years), or late (≥5 years) intensification groups. We estimated the age-stratified risks of micro- and macrovascular complications among these groups compared with those with optimal glycaemia (glycated haemoglobin <7%). RESULTS Of the 13 916 people with suboptimal glycaemia, 52.5% (n = 7304) did not receive any treatment intensification. In those aged <65 years, compared with the optimal glycaemia group late intensification was associated with a 56% higher risk of macrovascular complications (adjusted hazard ratio 1.56; 95% confidence intervals 1.08, 2.26). In elderly people (≥65 years), late intensification was associated with a higher risk of cardiovascular-related death (1.62; 1.03, 2.54) and a lower risk of microvascular complications (0.26; 0.08, 0.83). CONCLUSIONS Those who had late intensification were at an increased risk of cardiovascular death if they were ≥65 years and an increased risk of macrovascular complications if they were <65 years. These findings highlight the critical need for earlier intensification of treatment and adopting personalized treatment strategies to improve patient outcomes.
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Affiliation(s)
- Sharmin Shabnam
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Sophia Abner
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- IQVIA, London, UK
| | - Clare L Gillies
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Terry Dex
- Department of Medical Affairs, Sanofi, Bridgewater, New Jersey, USA
| | - Kamlesh Khunti
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - David R Webb
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Samuel Seidu
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
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Orfanoudaki A, Cook CB, Saghafian S, Castro J, Kosiorek HE, Chakkera HA. Diabetes mellitus and blood glucose variability increases the 30-day readmission rate after kidney transplantation. Clin Transplant 2024; 38:e15177. [PMID: 37922214 DOI: 10.1111/ctr.15177] [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: 08/30/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Inpatient hyperglycemia is an established independent risk factor among several patient cohorts for hospital readmission. This has not been studied after kidney transplantation. Nearly one-third of patients who have undergone a kidney transplant reportedly experience 30-day readmission. METHODS Data on first-time solitary kidney transplantations were retrieved between September 2015 and December 2018. Information was linked to the electronic health records to determine diagnosis of diabetes mellitus and extract glucometric and insulin therapy data. Univariate logistic regression analysis and the XGBoost algorithm were used to predict 30-day readmission. We report the average performance of the models on the testing set on bootstrapped partitions of the data to ensure statistical significance. RESULTS The cohort included 1036 patients who received kidney transplantation; 224 (22%) experienced 30-day readmission. The machine learning algorithm was able to predict 30-day readmission with an average area under the receiver operator curve (AUC) of 78% with (76.1%, 79.9%) 95% confidence interval (CI). We observed statistically significant differences in the presence of pretransplant diabetes, inpatient-hyperglycemia, inpatient-hypoglycemia, minimum and maximum glucose values among those with higher 30-day readmission rates. The XGBoost model identified the index admission length of stay, presence of hyper- and hypoglycemia, the recipient and donor body mass index (BMI) values, presence of delayed graft function, and African American race as the most predictive risk factors of 30-day readmission. Additionally, significant variations in the therapeutic management of blood glucose by providers were observed. CONCLUSIONS Suboptimal glucose metrics during hospitalization after kidney transplantation are associated with an increased risk for 30-day hospital readmission. Optimizing hospital blood glucose management, a modifiable factor, after kidney transplantation may reduce the risk of 30-day readmission.
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Affiliation(s)
- Agni Orfanoudaki
- University of Oxford, England, Oxford, UK
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts, USA
| | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Soroush Saghafian
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts, USA
| | - Janna Castro
- Department of Information Technology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Pichardo-Lowden AR, Haidet P, Umpierrez GE, Lehman EB, Quigley FT, Wang L, Rafferty CM, DeFlitch CJ, Chinchilli VM. Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay. Diabetes Care 2022; 45:2526-2534. [PMID: 36084251 PMCID: PMC9679255 DOI: 10.2337/dc21-0829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Paul Haidet
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Humanities and the Woodward Center for Excellence in Health Sciences Education, Penn State College of Medicine, Hershey, PA
| | | | - Erik B. Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Francis T. Quigley
- Department of Medicine, Penn State Health St. Joseph Medical Center, Reading, PA
| | - Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Colleen M. Rafferty
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Christopher J. DeFlitch
- Department of Emergency Medicine, Office of the Chief Medical Information Officer, Penn State Health, Hershey, PA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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Vellanki P, Cardona S, Galindo RJ, Urrutia MA, Pasquel FJ, Davis GM, Fayfman M, Migdal A, Peng L, Umpierrez GE. Efficacy and Safety of Intensive Versus Nonintensive Supplemental Insulin With a Basal-Bolus Insulin Regimen in Hospitalized Patients With Type 2 Diabetes: A Randomized Clinical Study. Diabetes Care 2022; 45:2217-2223. [PMID: 35675498 PMCID: PMC9643128 DOI: 10.2337/dc21-1606] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 04/26/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Administration of supplemental sliding scale insulin for correction of hyperglycemia in non-intensive care unit (ICU) patients with type 2 diabetes is frequently used with basal-bolus insulin regimens. In this noninferiority randomized controlled trial we tested whether glycemic control is similar with and without aggressive sliding scale insulin treatment before meals and bedtime in patients treated with basal-bolus insulin regimens. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes with admission blood glucose (BG) 140-400 mg/dL treated with basal-bolus insulin were randomized to intensive (correction for BG >140 mg/dL, n = 108) or to nonintensive (correction for BG >260 mg/dL, n = 107) administration of rapid-acting sliding scale insulin before meals and bedtime. The groups received the same amount of sliding scale insulin for BG >260 mg/dL. Primary outcome was difference in mean daily BG levels between the groups during hospitalization. RESULTS Mean daily BG in the nonintensive group was noninferior to BG in the intensive group with equivalence margin of 18 mg/dL (intensive 172 ± 38 mg/dL vs. nonintensive 173 ± 43 mg/dL, P = 0.001 for noninferiority). There were no differences in the proportion of target BG readings of 70-180 mg/dL, <70 or <54 mg/dL (hypoglycemia), or >350 mg/dL (severe hyperglycemia) or total, basal, or prandial insulin doses. Significantly fewer subjects received sliding scale insulin in the nonintensive (n = 36 [34%]) compared with the intensive (n = 98 [91%] [P < 0.0001]) group with no differences in sliding scale insulin doses between the groups among those who received sliding scale insulin (intensive 7 ± 4 units/day vs. nonintensive 8 ± 4 units/day, P = 0.34). CONCLUSIONS Among non-ICU patients with type 2 diabetes on optimal basal-bolus insulin regimen with moderate hyperglycemia (BG <260 mg/dL), a less intensive sliding scale insulin treatment did not significantly affect glycemic control.
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Affiliation(s)
- Priyathama Vellanki
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Saumeth Cardona
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Rodolfo J. Galindo
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Maria A. Urrutia
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Francisco J. Pasquel
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Georgia M. Davis
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Maya Fayfman
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Alexandra Migdal
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
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Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes. Can J Diabetes 2021; 46:99-107.e5. [PMID: 34210609 DOI: 10.1016/j.jcjd.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 03/25/2021] [Accepted: 04/26/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada. METHODS A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management. RESULTS Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care. CONCLUSIONS It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.
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Pichardo-Lowden A, Umpierrez G, Lehman EB, Bolton MD, DeFlitch CJ, Chinchilli VM, Haidet PM. Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes. BMJ Open Diabetes Res Care 2021; 9:9/1/e001557. [PMID: 33462075 PMCID: PMC7816906 DOI: 10.1136/bmjdrc-2020-001557] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Innovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations. RESEARCH DESIGN AND METHODS The tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9-4.4 mmol/L (70-80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods. RESULTS When active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, p<0.001). Hypoglycemia or impending hypoglycemia (1548 vs 1349, OR=1.15, p=0.050) were unrelated to the CDS tool on subsequent analysis. Inappropriate use of SSI monotherapy in type 1 diabetes (10 vs 22, OR=0.36, p=0.073), inappropriate use of SSI monotherapy in type 2 diabetes (2519 vs 2748, OR=0.97, p=0.632), and in stress hyperglycemia subjects (1617 vs 1488, OR=1.30, p<0.001) were recognized. CONCLUSION EMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.
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Affiliation(s)
- Ariana Pichardo-Lowden
- Department of Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Matthew D Bolton
- Department of Information Services, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christopher J DeFlitch
- Department of Emergency Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Paul M Haidet
- Department of Medicine, Public Health Sciences, and Humanities, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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Cohen E, Korah M, Callender G, Belfort de Aguiar R, Haakinson D. Metabolic Disorders with Kidney Transplant. Clin J Am Soc Nephrol 2020; 15:732-742. [PMID: 32284323 PMCID: PMC7269213 DOI: 10.2215/cjn.09310819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Metabolic disorders are highly prevalent in kidney transplant candidates and recipients and can adversely affect post-transplant graft outcomes. Management of diabetes, hyperparathyroidism, and obesity presents distinct opportunities to optimize patients both before and after transplant as well as the ability to track objective data over time to assess a patient's ability to partner effectively with the health care team and adhere to complex treatment regimens. Optimization of these particular disorders can most dramatically decrease the risk of surgical and cardiovascular complications post-transplant. Approximately 60% of nondiabetic patients experience hyperglycemia in the immediate post-transplant phase. Multiple risk factors have been identified related to development of new onset diabetes after transplant, and it is estimated that upward of 7%-30% of patients will develop new onset diabetes within the first year post-transplant. There are a number of medications studied in the kidney transplant population for diabetes management, and recent data and the risks and benefits of each regimen should be optimized. Secondary hyperparathyroidism occurs in most patients with CKD and can persist after kidney transplant in up to 66% of patients, despite an initial decrease in parathyroid hormone levels. Parathyroidectomy and medical management are the options for treatment of secondary hyperparathyroidism, but there is no randomized, controlled trial providing clear recommendations for optimal management, and patient-specific factors should be considered. Obesity is the most common metabolic disorder affecting the transplant population in both the pre- and post-transplant phases of care. Not only does obesity have associations and interactions with comorbid illnesses, such as diabetes, dyslipidemia, and cardiovascular disease, all of which increase morbidity and mortality post-transplant, but it also is intimately inter-related with access to transplantation for patients with kidney failure. We review these metabolic disorders and their management, including data in patients with kidney transplants.
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Affiliation(s)
- Elizabeth Cohen
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut
| | - Maria Korah
- Yale University School of Medicine, New Haven, Connecticut
| | - Glenda Callender
- Department of Surgery, Section of Endocrine Surgery, Yale University, New Haven, Connecticut
| | | | - Danielle Haakinson
- Department of Surgery, Section of Transplant, Yale University, New Haven, Connecticut
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Continuous Glucose Monitoring in Bariatric Patients Undergoing Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-En-Y Gastric Bypass. Obes Surg 2020; 29:1317-1326. [PMID: 30737761 DOI: 10.1007/s11695-018-03684-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Few investigations have been conducted that compared blood glucose in patients with diabetes mellitus (DM2) and morbid obesity who had undergone laparoscopic sleeve gastrectomy (LSG) or gastric bypass (LRYGB). We aimed to compare the effects of these procedures using continuous glucose monitoring (CGM). METHODS We prospectively studied patients that had qualified for LSG or LRYGB. The inclusion criteria were DM2 of ≤ 5 years, for which patients were taking oral anti-diabetic drugs, or no glucose metabolism disorder; and morbid obesity. CGM was performed between admission and the 10th postoperative day. RESULTS We studied 16 patients with DM2 and 16 without. Eighteen patients underwent LSG and 14 underwent LRYGB. The median hemoglobin A1c was 5.5% (5.4-5.9%) in DM2 patients, which did not differ from control (p = 0.460). Preoperative mean daily glucose concentration was similar between DM2 and control patients (p = 0.622). For patients with DM2, LRYGB was associated with more frequent low glucose status, and these episodes lasted longer than in DM2 patients that underwent LSG (p = 0.035 and 0.049, respectively). DM2 patients that underwent LRYGB demonstrated lower glucose concentrations from third postoperative day than those that underwent LSG. Patients without DM2 did not demonstrate differences in daily mean glucose concentrations, or in incidence nor duration of hypoglycemia throughout the observation period. CONCLUSION A significantly larger reduction in interstitial glucose concentration is present from third day in patients with DM2 who undergo LRYGB vs. LSG, accompanied by a lower incidence and shorter duration of low glucose episodes.
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Sriphrapradang C, Mongkolrattanakul P, Tanasanitkul H, Reutrakul S. Improving inpatient glycemic control by diabetes education program in internal medicine residents. Diabetes Metab Syndr 2019; 13:2647-2652. [PMID: 31405689 DOI: 10.1016/j.dsx.2019.07.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
AIMS The purpose of this study was to investigate the effectiveness of an inpatient diabetes care education during the first year of internal medicine residency training on inpatient glycemic control. METHODS The program was comprised of 1-hr small group teaching per 4-week rotation and twice-a-week morning insulin round by an endocrinologist. Inpatient insulin management guideline leaflet was provided to all internal medicine residents. We retrospectively collected the point-of-care testing for glucose (POCT-glu) data in patients admitted to the general medicine wards and compared the mean of blood glucose (BG) before and after the education program. A total of 134438 POCT-glu values from 7055 patients were analyzed. RESULTS After the initiation of the education program, mean BG levels significantly decreased during the first year and were lowest during the second year after education (Mean BG at baseline was 161.38 ± 64.10 mg/dL; 1st year, 159.48 ± 62.53 mg/dL and 2nd year, 155.60 ± 64.94 mg/dL, p-value < 0.0001). The reduction of BG levels was more pronounced in the patients with previously undiagnosed diabetes mellitus than patients with underlying diabetes mellitus. The rates of severe hypoglycemia (defined by BG < 40 mg/dL or 2.2 mmol/L) were not significantly different before and after education (baseline 0.12%, 1st year 0.14%, and 2nd year 0.14%, p-value = 0.632). CONCLUSIONS Lack of confidence and inadequate knowledge of insulin treatment in physicians were important barriers to glycemic management. Consistent education in internal medicine residents led to a significant improvement in inpatient glycemic control.
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Affiliation(s)
- Chutintorn Sriphrapradang
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand.
| | - Pannawat Mongkolrattanakul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Hataiporn Tanasanitkul
- Department of Health Informatics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Sirimon Reutrakul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
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Pichardo-Lowden A, Farbaniec M, Haidet P. Overcoming barriers to diabetes care in the hospital: The power of qualitative observations to promote positive change. J Eval Clin Pract 2019; 25:448-455. [PMID: 30378222 PMCID: PMC6563155 DOI: 10.1111/jep.13057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/21/2018] [Accepted: 10/04/2018] [Indexed: 01/08/2023]
Abstract
AIMS Despite advocacy by diabetes societies and evidence about how to prevent the deleterious consequences of dysglycemia among hospitalized patients, deficits in clinical practice continue to present barriers to care. The purpose of this study was to examine inpatient rounding practices using a qualitative research lens to assess challenges on the care of hospitalized patients with diabetes and to develop ideas for positive changes in hospital management of diabetes and hyperglycemia. METHODS We conducted an interpretive analysis of qualitative observations during medical and surgical inpatient rounds at an academic institution. We coded, analysed, and reported data as thematic findings. RESULTS Emerging themes include omissions in discussions during rounds; unpreparedness to address diabetes or dysglycemia during rounds; identifying practice improvement opportunities to address diabetes issues: and recognizing accountability within the routine of practice. CONCLUSIONS This work guides clinicians and informs systems of practice about improvement strategies that can emerge from within hospital teams. These recommendations emphasize the interconnectedness of practice elements including thoughtful review of glucose status during rounds among patients with and without diabetes; fostering doctors and nurses to work in unison; promoting awareness and integration within and across disciplines; and advocating for better use of existing resources.
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Affiliation(s)
- Ariana Pichardo-Lowden
- Department of Medicine, Division of Endocrinology, Penn State University, Hershey, PA, USA.,College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA
| | - Michelle Farbaniec
- College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA
| | - Paul Haidet
- College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA.,Departments of Medicine, Humanities, and Public Health Sciences, and the Woodward Center for Excellence in Health Sciences Education Penn State University, Hershey, PA, USA
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Basal-bolus insulin therapy in postoperative inpatients with diabetes mellitus: directions for future quality-improvement initiatives. Future Sci OA 2017; 4:FSO256. [PMID: 29255628 PMCID: PMC5729596 DOI: 10.4155/fsoa-2017-0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/22/2017] [Indexed: 11/17/2022] Open
Abstract
Aim To determine variables associated with hyperglycemia and insulin therapy in postoperative inpatients with diabetes mellitus following a quality-improvement initiative. Materials & methods Patients with diabetes mellitus following an elective surgical procedure (n = 782; 877 surgical procedures) were selected. Results Age, hemoglobin A1c corticosteroids, insulin therapy and year of surgery were associated (p < 0.01) with hyperglycemia. Hemoglobin A1c, hyperglycemia, case mix index and corticosteroids were associated (p ≤ 0.03) with insulin therapy. Hyperglycemia and use of insulin varied by surgical specialty. Conclusion Data could be used to modify current treatment algorithms. Variations in hyperglycemia and insulin use by surgical specialty require further investigation.
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Abstract
PURPOSE OF REVIEW Glucometrics is the systematic analysis of inpatient glucose data and is of key interest as hospitals strive to improve inpatient glycemic control. Insulinometrics is the systematic analysis and reporting of inpatient insulin therapy. This paper reviews some of the questions to be resolved before a national benchmarking process can be developed that will allow institutions to track and compare inpatient glucose control performance against established guidelines. RECENT FINDINGS There remains a lack of standardization on how glucometircs should be measured and reported. Before hospitals can commit resources to compiling and extracting data, consensus must be reached on such questions as which measures to report, definitions of glycemic targets, and how data should be obtained. Examples are provided on how insulin administration can be measured and reported. Hospitals should begin assessment of glucometrics and insulinometrics. However, consensus and standardization must first occur to allow for a national benchmarking process.
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Affiliation(s)
- Bithika M Thompson
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
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Cook CB, Apsey HA, Habermann EB, Glasgow AE, Castro JC, Schlinkert RT. UPDATE ON A QUALITY INITIATIVE TO OVERCOME CLINICAL INERTIA IN THE POSTOPERATIVE CARE OF INPATIENTS WITH DIABETES MELLITUS. Endocr Pract 2017; 23:498-500. [PMID: 28095039 DOI: 10.4158/ep161621.co] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Pichardo-Lowden A, Haidet P, Umpierrez GE. PERSPECTIVES ON LEARNING AND CLINICAL PRACTICE IMPROVEMENT FOR DIABETES IN THE HOSPITAL: A REVIEW OF EDUCATIONAL INTERVENTIONS FOR PROVIDERS. Endocr Pract 2017; 23:614-626. [PMID: 28225312 DOI: 10.4158/ep161634.ra] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The management of inpatient hyperglycemia and diabetes requires expertise among many health-care providers. There is limited evidence about how education for healthcare providers can result in optimization of clinical outcomes. The purpose of this critical review of the literature is to examine methods and outcomes related to educational interventions regarding the management of diabetes and dysglycemia in the hospital setting. This report provides recommendations to advance learning, curricular planning, and clinical practice. METHODS We conducted a literature search through PubMed Medical for terms related to concepts of glycemic management in the hospital and medical education and training. This search yielded 1,493 articles published between 2003 and 2016. RESULTS The selection process resulted in 16 original articles encompassing 1,123 learners from various disciplines. We categorized findings corresponding to learning outcomes and patient care outcomes. CONCLUSION Based on the analysis, we propose the following perspectives, leveraging learning and clinical practice that can advance the care of patients with diabetes and/or dysglycemia in the hospital. These include: (1) application of knowledge related to inpatient glycemic management can be improved with active, situated, and participatory interactions of learners in the workplace; (2) instruction about inpatient glycemic management needs to reach a larger population of learners; (3) management of dysglycemia in the hospital may benefit from the integration of clinical decision support strategies; and (4) education should be adopted as a formal component of hospitals' quality planning, aiming to integrate clinical practice guidelines and to optimize diabetes care in hospitals.
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Identifying Gaps in Inpatient Care of Patients with Diabetes Mellitus: Where Do We Go From Here? Jt Comm J Qual Patient Saf 2017; 43:16-17. [DOI: 10.1016/j.jcjq.2016.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Relationship between the timing of preoperative medical visits and day-of-surgery glucose in poorly controlled diabetes. Future Sci OA 2016; 2:FSO123. [PMID: 28031970 PMCID: PMC5137843 DOI: 10.4155/fsoa-2016-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/15/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study evaluated referral patterns for preoperative evaluations of patients with poorly controlled diabetes mellitus (DM) and determined whether intervals between evaluations and surgery day were associated with preoperative glucose levels. RESULTS/METHODOLOGY In this retrospective analysis of DM patients with a hemoglobin A1c level greater than 8.0%, of the 163 patients who underwent preoperative medical evaluation, only 45% were evaluated by endocrinology. Patients who had surgery earlier than 10 days after the preoperative medical evaluation had preoperative glucose levels 18% higher than those of patients who waited more than 10 days. Preoperative outpatient contact with endocrinology was not associated with preoperative glucose level (p = 0.90). CONCLUSION For poorly controlled DM, more than 10 days are needed to achieve preoperative glycemic control.
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Apsey HA, Coan KE, Castro JC, Jameson KA, Schlinkert RT, Cook CB. Overcoming clinical inertia in the management of postoperative patients with diabetes. Endocr Pract 2016; 20:320-8. [PMID: 24246354 DOI: 10.4158/ep13366.or] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the impact of an intervention designed to increase basal-bolus insulin therapy administration in postoperative patients with diabetes mellitus. METHODS Educational sessions and direct support for surgical services were provided by a nurse practitioner (NP). Outcome data from the intervention were compared to data from a historical (control) period. Changes in basal-bolus insulin use were assessed according to hyperglycemia severity as defined by the percentage of glucose measurements >180 mg/dL. RESULTS Patient characteristics were comparable for the control and intervention periods (all P≥.15). Overall, administration of basal-bolus insulin occurred in 9% (8/93) of control and in 32% (94/293) of intervention cases (P<.01). During the control period, administration of basal-bolus insulin did not increase with more frequent hyperglycemia (P = .22). During the intervention period, administration increased from 8% (8/96) in patients with the fewest number of hyperglycemic measurements to 60% (57/95) in those with the highest frequency of hyperglycemia (P<.01). The mean glucose level was lower during the intervention period compared to the control period (149 mg/dL vs. 163 mg/dL, P<.01). The proportion of glucose values >180 mg/dL was lower during the intervention period than in the control period (21% vs. 31% of measurements, respectively, P<.01), whereas the hypoglycemia (glucose >70 mg/dL) frequencies were comparable (P = .21). CONCLUSION An intervention to overcome clinical inertia in the management of postoperative patients with diabetes led to greater utilization of basal-bolus insulin therapy and improved glucose control without increasing hypoglycemia. These efforts are ongoing to ensure the delivery of effective inpatient diabetes care by all surgical services.
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Affiliation(s)
- Heidi A Apsey
- Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Kathryn E Coan
- Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Janna C Castro
- Department of Information Technology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Kimberly A Jameson
- Division of Planning Services and Practice Analysis, Mayo Clinic, Scottsdale, Arizona
| | | | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Scottsdale, Arizona
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Khunti K, Nikolajsen A, Thorsted BL, Andersen M, Davies MJ, Paul SK. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes Obes Metab 2016; 18:401-9. [PMID: 26743666 PMCID: PMC5067688 DOI: 10.1111/dom.12626] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 11/30/2015] [Accepted: 12/29/2015] [Indexed: 12/13/2022]
Abstract
AIM To investigate whether clinical inertia, the failure to intensify treatment regimens when required, exists in people with type 2 diabetes treated with basal insulin. METHODS This was a retrospective cohort study involving patients with type 2 diabetes in the UK Clinical Practice Research Datalink database between January 2004 and December 2011, with follow-up until December 2013. RESULTS A total of 11 696 patients were included in the analysis. Among all patients, 36.5% had their treatment intensified during the study period; of these, the treatment of 50.0, 42.5 and 7.4% was intensified with bolus or premix insulin or glucagon-like peptide-1 receptor agonists, respectively. The median time from initiation of basal insulin to treatment intensification was 4.3 years [95% confidence interval (CI) 4.1, 4.6]. Among patients clinically eligible for treatment intensification [glycated haemoglobin (HbA1c) ≥7.5% (58 mmol/mol)], 30.9% had their treatment regimen intensified. The median time to intensification in this group was 3.7 years (95% CI 3.4, 4.0). Increasing age, duration of diabetes, oral antihyperglycaemic agent usage and Charlson comorbidity index score were associated with a significant delay in the time to intensification (p < 0.05). Among patients with HbA1c ≥7.5% (58 mmol/mol), 32.1% stopped basal insulin therapy. CONCLUSIONS Strategies should be developed to increase the number of patients undergoing therapy intensification and to reduce the delay in intensifying therapy for suitable patients on basal insulin. Initiatives to support patients continuing on insulin are also required.
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Affiliation(s)
- K. Khunti
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
| | | | | | | | - M. J. Davies
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
| | - S. K. Paul
- Clinical Trials & Biostatistics UnitQIMR Berghofer Medical Research InstituteBrisbaneAustralia
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Hyperglycemia during the immediate period following liver transplantation. Future Sci OA 2016; 2:FSO97. [PMID: 28031946 PMCID: PMC5138006 DOI: 10.4155/fsoa-2015-0010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/04/2016] [Indexed: 01/14/2023] Open
Abstract
Aim: High blood glucose levels in the hospital are common among transplant recipients. Methods: Retrospective analysis, stratified by diagnosis of pretransplant diabetes mellitus (DM). Results: Of 346 patients, 96 had pretransplant DM (insulin, n = 60; no insulin, n = 36) and 250 did not. Patients with pretransplant DM had higher inpatient mean glucose levels and more hyperglycemia and hypoglycemia (all p < 0.01). For patients without pretransplant DM, the need for insulin at discharge increased 23% for every 5-year age increase (odds ratio: 1.23; 95% CI: 1.06–1.44; p = 0.007) and 51% for every five units of glucose measurements >180 mg/dl (OR: 1.51; 95% CI: 1.23–1.95; p < 0.01). Conclusion: Inpatient hyperglycemia was common in liver transplant recipients. Hospital practitioners must anticipate the need to teach self-management skills to liver transplant recipients. Lay abstract: High blood glucose levels (also known as hyperglycemia) in the hospital are common among patients who have received a transplant. The authors conducted a study to determine how often high blood glucose values occurred in patients who received a liver transplant and found that values were highest in people who had diabetes before the transplant. However, even patients who did not have a history of diabetes had hyperglycemia and needed insulin treatment. Providers caring for these patients in the hospital must be prepared to provide education in diabetes self-management skills to virtually all patients undergoing a liver transplant.
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Thompson BM, Stearns JD, Apsey HA, Schlinkert RT, Cook CB. Perioperative Management of Patients with Diabetes and Hyperglycemia Undergoing Elective Surgery. Curr Diab Rep 2016; 16:2. [PMID: 26699765 DOI: 10.1007/s11892-015-0700-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetes mellitus (DM) and hyperglycemia are associated with increased surgical morbidity and mortality. Hyperglycemia is a determinant of risk of surgical complications and should be addressed across the continuum of surgical care. While data support the need to address hyperglycemia in patients with DM in the ambulatory setting prior to surgery and in the inpatient setting, data are less certain about hyperglycemia occurring during the perioperative period-that part of the process occurring on the day of surgery itself. The definition of "perioperative" varies in the literature. This paper proposes a standardized definition for the perioperative period as spanning the time of patient admission to the preoperative area through discharge from the recovery area. Available information about the impact of perioperative hyperglycemia on surgical outcomes within the framework of that definition is summarized, and the authors' approach to standardizing perioperative care for patients with DM is outlined, including the special case of patients receiving insulin pump therapy. The discussion is limited to adult ambulatory non-obstetric patients undergoing elective surgical procedures under general anesthesia.
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Affiliation(s)
- Bithika M Thompson
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Joshua D Stearns
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Heidi A Apsey
- Division of General Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | | | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
- Division of Preventative, Occupational and Aerospace Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Paul SK, Klein K, Thorsted BL, Wolden ML, Khunti K. Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes. Cardiovasc Diabetol 2015; 14:100. [PMID: 26249018 PMCID: PMC4528846 DOI: 10.1186/s12933-015-0260-x] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 07/18/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of the study was to evaluate the effect of delay in treatment intensification (IT; clinical inertia) in conjunction with glycaemic burden on the risk of macrovascular events (CVE) in type 2 diabetes (T2DM) patients. METHODS A retrospective cohort study was carried out using United Kingdom Clinical Practice Research Datalink, including T2DM patients diagnosed from 1990 with follow-up data available until 2012. RESULTS In the cohort of 105,477 patients mean HbA1c was 8.1% (65 mmol/mol) at diagnosis, 11% had a history of cardiovascular disease, and 7.1% experienced at least one CVE during 5.3 years of median follow-up. In patients with HbA1c consistently above 7/7.5% (53/58 mmol/mol, n = 23,101/11,281) during 2 years post diagnosis, 26/22% never received any IT. Compared to patients with HbA1c <7% (<53 mmol/mol), in patients with HbA1c ≥7% (≥53 mmol/mol), a 1 year delay in receiving IT was associated with significantly increased risk of MI, stroke, HF and composite CVE by 67% (HR CI: 1.39, 2.01), 51% (HR CI: 1.25, 1.83), 64% (HR CI: 1.40, 1.91) and 62% (HR CI: 1.46, 1.80) respectively. One year delay in IT in interaction with HbA1c above 7.5% (58 mmol/mol) was also associated with similar increased risk of CVE. CONCLUSIONS Among patients with newly diagnosed T2DM, 22% remained under poor glycaemic control over 2 years, and 26% never received IT. Delay in IT by 1 year in conjunction with poor glycaemic control significantly increased the risk of MI, HF, stroke and composite CVE.
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Affiliation(s)
- Sanjoy K Paul
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Brisbane, QLD, 4006, Australia.
| | - Kerenaftali Klein
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Brisbane, QLD, 4006, Australia.
| | | | | | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK.
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Shah M, Apsey HA, Stearns JD, Schlinkert RT, Seifert KM, Cook CB. Guidelines to improve perioperative management of diabetes mellitus: an example of a successful quality initiative. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/dmt.14.26] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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