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Thabit H, Schofield J. Technology in the management of diabetes in hospitalised adults. Diabetologia 2024:10.1007/s00125-024-06206-4. [PMID: 38953925 DOI: 10.1007/s00125-024-06206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
Suboptimal glycaemic management in hospitals has been associated with adverse clinical outcomes and increased financial costs to healthcare systems. Despite the availability of guidelines for inpatient glycaemic management, implementation remains challenging because of the increasing workload of clinical staff and rising prevalence of diabetes. The development of novel and innovative technologies that support the clinical workflow and address the unmet need for effective and safe inpatient diabetes care delivery is still needed. There is robust evidence that the use of diabetes technology such as continuous glucose monitoring and closed-loop insulin delivery can improve glycaemic management in outpatient settings; however, relatively little is known of its potential benefits and application in inpatient diabetes management. Emerging data from clinical studies show that diabetes technologies such as integrated clinical decision support systems can potentially mediate safer and more efficient inpatient diabetes care, while continuous glucose sensors and closed-loop systems show early promise in improving inpatient glycaemic management. This review aims to provide an overview of current evidence related to diabetes technology use in non-critical care adult inpatient settings. We highlight existing barriers that may hinder or delay implementation, as well as strategies and opportunities to facilitate the clinical readiness of inpatient diabetes technology in the future.
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Affiliation(s)
- Hood Thabit
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Jonathan Schofield
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Barmanray RD, Kyi M, Colman PG, Fourlanos S. Longitudinal Digital Glucometric Benchmarking to Evaluate the Impact of Institutional Diabetes Care Initiatives in Adults With Diabetes Mellitus Over the 2016-2020 Period. J Diabetes Sci Technol 2024; 18:610-617. [PMID: 36412187 PMCID: PMC11089860 DOI: 10.1177/19322968221140126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND While glucometric benchmarking has been used to compare glucose management between institutions, the value of longitudinal intra-institution benchmarking to assess quality improvement changes is not established. METHODS A prospective six-month observational study (October 2019-March 2020 inclusive) of inpatients with diabetes or newly detected hyperglycemia admitted to eight medical and surgical wards at the Royal Melbourne Hospital. Networked blood glucose (BG) meters were used to collect capillary BG levels. Outcomes were measures of glycemic control assessed by mean and threshold glucometric measures and comparison with published glucometric benchmarks. Intra-institution comparison was over the 2016-2020 period. RESULTS In all, 620 admissions (588 unique individuals) met the inclusion criteria, contributing 15 164 BG results over 4023 admission-days. Compared with the 2016 cohort from the same institution, there was increased BG testing (3.8 [SD = 2.2) vs 3.3 [SD = 1.7] BG measurements per patient-day, P < .001), lower mean patient-day mean glucose (PDMG; 8.9 mmol/L [SD = 3.2] vs 9.5 mmol/L [SD = 3.3], P < .001), and reduced mean and threshold measures of hyperglycemia (P < .001 for all). Comparison with institutions across the United States revealed lower incidence of mean PDMG >13.9 or >16.7 mmol/L, and reduced hypoglycemia (<3.9, <2.8, and <2.2 mmol/L), when compared with published benchmarks from an earlier period (2009-2014). CONCLUSIONS Comprehensive digital-based glucometric benchmarking confirmed institutional quality improvement changes were followed by reduced hyperglycemia and hypoglycemia in a five-year comparison. Longitudinal glucometric benchmarking enables evaluation and validation of changes to institutional diabetes care management practices.
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Affiliation(s)
- Rahul D Barmanray
- Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, VIC, Australia
| | - Mervyn Kyi
- Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, VIC, Australia
| | - Peter G. Colman
- Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Spiros Fourlanos
- Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, VIC, Australia
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Chang C, Fleires A, Alshaikhli A, Arredondo H, Gavilanes D, Cabral-Amador FJ, Cantu J, Bazan D, Oliveira KO, Verduzco R, Pedraza L. Improving inpatient hyperglycaemia in non-critically ill adults in resident wards through audit and feedback. BMJ Open Qual 2024; 13:e002480. [PMID: 38429063 PMCID: PMC10910419 DOI: 10.1136/bmjoq-2023-002480] [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: 06/30/2023] [Accepted: 02/11/2024] [Indexed: 03/03/2024] Open
Abstract
Inpatient hyperglycaemia is associated with an increase in morbidity and mortality, number of rehospitalisations and length of hospitalisation. Although the advantages of proper glycaemic control in hospitalised patients with diabetes are well established, a variety of barriers limit accomplishment of blood glucose targets. Our primary aim was to decrease the number of glucose values above 180 mg/dL in non-critical care hospitalised patients using an audit and feedback intervention with pharmacy and internal medicine residents. A resident-led multidisciplinary team implemented the quality improvement (QI) project including conception, literature review, educating residents, iterative development of audit and feedback tools and data analysis. The multidisciplinary team met every 5 weeks and undertook three 'plan-do-study-act' cycles over an 8-month intervention period (August 2022 to March 2023) to educate residents on inpatient hyperglycaemia management, develop and implement an audit and feedback process and assess areas for improvement. We performed 1045 audits analysing 16 095 accu-checks on 395 non-duplicated patients. Most audits showed compliance with guidelines. The monthly run-on chart shows per cent of glucose values above 180 mg/dL in our non-ICU hospitalised patients and an overall pre-to-post comparison of 25.1%-23.0% (p value<0.05). The intervention was well accepted by residents evidenced by survey results. We did not meet our primary aim to reduce hyperglycaemia by 30% and this combined with the audits showing mostly compliance with guidelines suggests that prescribing behaviour was not a key driver of inpatient hyperglycaemia in our population. This internal medicine resident and pharmacy interprofessional collaboration with audit and feedback for inpatient hyperglycaemia was feasible, well accepted and had a statistically significant yet small improvement in inpatient hyperglycaemia. The project may be helpful to others wishing to explore inpatient hyperglycaemia, interprofessional QI with pharmacists, resident-led QI and audit and feedback.
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Affiliation(s)
- Chelsea Chang
- Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Alcibiades Fleires
- Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Alfarooq Alshaikhli
- Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Hector Arredondo
- Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Diana Gavilanes
- Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Francisco J Cabral-Amador
- Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | | | - Daniela Bazan
- DHR Health, Edinburg, Texas, USA
- Irma Lerma Rangel School of Pharmacy, Texas A&M Health Science Center, College Station, Texas, USA
| | | | - Rene Verduzco
- DHR Health, Edinburg, Texas, USA
- Irma Lerma Rangel School of Pharmacy, Texas A&M Health Science Center, College Station, Texas, USA
| | - Lina Pedraza
- Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
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Irace C, Coluzzi S, Di Cianni G, Forte E, Landi F, Rizzo MR, Sesti G, Succurro E, Consoli A. Continuous glucose monitoring (CGM) in a non-Icu hospital setting: The patient's journey. Nutr Metab Cardiovasc Dis 2023; 33:2107-2118. [PMID: 37574433 DOI: 10.1016/j.numecd.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023]
Abstract
AIMS Although consistent data support the outpatient use of continuous glucose monitoring (CGM) to improve glycemic control and reduce hypoglycemic burden, and clinical outcomes, there are limited data regarding its use in the hospital setting, particularly in the non-intensive care unit (non-ICU) setting. The emerging use of CGM in the non-critical care setting may be useful in increasing the efficiency of hospital care and reducing the length of stay for patients with diabetes while improving glycemic control. DATA SYNTHESIS The purpose of this Expert Opinion paper was to evaluate the state of the art and provide a practical model of how CGM can be implemented in the hospital. SETTING A patient's CGM journey from admission to the ward to the application of the sensor, from patient education on the device during hospitalization until discharge of the patient to maintain remote control. CONCLUSIONS This practical approach for the implementation and management of CGM in patients with diabetes admitted to non-ICUs could guide hospitals in their diabetes management initiatives using CGM, helping to identify patients most likely to benefit and suggesting how this technology can be implemented to maximize clinical benefits.
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Affiliation(s)
- Concetta Irace
- Department of Health Science, University Magna Graecia of Catanzaro, Catanzaro, Italy.
| | - Sara Coluzzi
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy
| | - Graziano Di Cianni
- ASL Tuscany Northwest, Diabetes and Metabolic Disease, Livorno Hospital, Livorno, Italy
| | | | - Francesco Landi
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosaria Rizzo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Elena Succurro
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Agostino Consoli
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy; Department of Medicine and Aging Sciences DMSI and Center for Advanced Studies and Technology CAST, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
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Dashora U, Flanagan D, Rayman G, Mustafa OG, Walden E, Dhatariya K. Optimal staffing for a good quality inpatient diabetes service. Diabet Med 2023; 40:e15151. [PMID: 37328941 DOI: 10.1111/dme.15151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/19/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Increasing numbers of people admitted to hospital have diabetes and need specialist support. To date, there is no mechanism which can help teams estimate the number of health care professionals they need to provide optimal care for people with diabetes in hospitals. METHODS The Joint British Diabetes Societies (JBDS) for Inpatient Care Group organised a survey of specialist inpatient diabetes teams in the UK for current staffing and the perception of optimal staffing using mailing lists available through their representative organisations. The results were verified and confirmed by one-to-one conversations with individual respondents and discussed in multiple expert-group meetings to agree on the results. RESULTS Responses were received from 17 Trusts covering 30 hospital sites. Current diabetes specialist staffing level per 100 people with diabetes in hospital (Median, IQR) for consultants was 0.24 (0.22-0.37), diabetes inpatient specialist nurses was 1.94 (1.22-2.6), dieticians was 0.00 (0.00-0.00), podiatrists was 0.19 (0.00-0.62), pharmacists was 0.00 (0.00-0.37), psychologists was 0.00 (0.00-0.00). The teams also reported that for optimal care the total staff needed for each group (Median, IQR) was much higher; consultants 0.65 (0.50-0.88), specialist nurses 3.38 (2.78-4.59), dieticians 0.48 (0.33-0.72), podiatrists, 0.93 (0.65-1.24), pharmacists, 0.65 (0.40-0.79) and psychologists 0.33 (0.27-0.58). Based on the results of the survey, the JBDS expert group produced an Excel calculator to estimate staffing needs of any hospital site in question just by populating a few of the cells. CONCLUSION Current inpatient diabetes staffing is much lower than needed in most Trusts who responded to the survey. The JBDS calculator can provide an estimate of the staffing needs of any hospital.
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Affiliation(s)
- U Dashora
- East Sussex Healthcare NHS Trust and Honorary Clinical Professor, Brighton and Sussex Medical School, Brighton, UK
| | - D Flanagan
- Plymouth Hospitals NHS Trust, Plymouth, UK
| | - G Rayman
- The Ipswich Hospital, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - O G Mustafa
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospital and Honorary Professor, Norwich Medical School, University of East Anglia, Norwich, UK
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Reynolds L, Luo Z, Singh K. Diabetic complications and prospective immunotherapy. Front Immunol 2023; 14:1219598. [PMID: 37483613 PMCID: PMC10360133 DOI: 10.3389/fimmu.2023.1219598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
The incidence of Diabetes Mellitus is increasing globally. Individuals who have been burdened with diabetes for many years often develop complications as a result of hyperglycemia. More and more research is being conducted highlighting inflammation as an important factor in disease progression. In all kinds of diabetes, hyperglycemia leads to activation of alternative glucose metabolic pathways, resulting in problematic by-products including reactive oxygen species and advanced glycation end products. This review takes a look into the pathogenesis of three specific diabetic complications; retinopathy, nephropathy and neuropathy as well as their current treatment options. By considering recent research papers investigating the effects of immunotherapy on relevant conditions in animal models, multiple strategies are suggested for future treatment and prevention of diabetic complications with an emphasis on molecular targets associated with the inflammation.
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S267-S278. [PMID: 36507644 PMCID: PMC9810470 DOI: 10.2337/dc23-s016] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Khan SA, Zilbermint M. Centers for Medicare & Medicaid Services' Hospital Harm Measures for Severe Hypoglycemia and Hyperglycemia: Is Your Hospital Ready? Diabetes Spectr 2022; 35:391-397. [PMID: 36561656 PMCID: PMC9668722 DOI: 10.2337/dsi22-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Poor inpatient glycemic management is associated with increased lengths of stay and in-hospital morbidity and mortality. Improving inpatient glycemic outcomes can be difficult because there are no standardized benchmarks, and many hospitals lack the capacity to electronically extract and analyze glucose data. The Centers for Medicare & Medicaid Services recently proposed new electronic clinical quality measures to be incorporated into its mandatory Hospital Inpatient Quality Reporting Program. Among these measures is an assessment of hospital harm from severe hypoglycemia and severe hyperglycemia. Hospitals must be ready to collect the necessary data for these new measures by January 2023. The new measures could bring welcome attention to the need to implement guideline-based inpatient glycemic management. However, some hospitals that serve high-risk populations may be at risk for losing funding if they are unable to comply.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes, and Metabolism, University of Maryland School of Medicine, Baltimore, MD
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, University of Maryland School of Medicine, Baltimore, MD
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Baltimore, MD
- Division of Endocrinology, Diabetes and Metabolism, Suburban Hospital, Bethesda, MD
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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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Kopanz J, Mader JK, Donsa K, Libiseller A, Aberer F, Pandis M, Reinisch-Gratzer J, Ambrosch GC, Lackner B, Truskaller T, Sinner FM, Pieber TR, Lichtenegger KM. Digital algorithm-guided insulin therapy in home healthcare for elderly persons with type 2 diabetes: A proof-of-concept study. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:986672. [PMID: 36992745 PMCID: PMC10012122 DOI: 10.3389/fcdhc.2022.986672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022]
Abstract
GlucoTab@MobileCare, a digital workflow and decision support system with integrated basal and basal-plus insulin algorithm was investigated for user acceptance, safety and efficacy in persons with type 2 diabetes receiving home health care by nurses. During a three months study nine participants (five female, age 77 ± 10 years, HbA1c 60 ± 13 mmol/mol (study start) vs. 57 ± 12 mmol/mol (study end) received basal or basal-plus insulin therapy as suggested by the digital system. In total 95% of all suggested tasks (blood glucose (BG) measurements, insulin dose calculations, insulin injections) were performed according to the digital system. Mean morning BG was 171 ± 68 mg/dL in the first study month vs. 145 ± 35 mg/dL in the last study month, indicating a reduced glycemic variability of 33 mg/dL (standard deviation). No hypoglycemic episode < 54 mg/dL occurred. User’s adherence was high and the digital system supported a safe and effective treatment. Larger scale studies are needed to confirm findings under routine care.German Clinical Trials Register IDDRKS00015059
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Affiliation(s)
- Julia Kopanz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Julia K. Mader
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Klaus Donsa
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
- *Correspondence: Klaus Donsa, ;
| | - Angela Libiseller
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Felix Aberer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Marlene Pandis
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | | | - Bettina Lackner
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Thomas Truskaller
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Frank Michael Sinner
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Thomas R. Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Katharina M. Lichtenegger
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
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Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, Hirsch IB, Luger A, McDonnell ME, Murad MH, Nielsen C, Pegg C, Rushakoff RJ, Santesso N, Umpierrez GE. Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2022; 107:2101-2128. [PMID: 35690958 PMCID: PMC9653018 DOI: 10.1210/clinem/dgac278] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management. OBJECTIVE To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia. METHODS A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes. CONCLUSION The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.
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Affiliation(s)
- Mary T Korytkowski
- University of Pittsburgh, Division of Endocrinology, Department of Medicine, Pittsburgh, PA, USA
| | - Ranganath Muniyappa
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Amy C Donihi
- University of Pittsburgh School of Pharmacy, Department of Pharmacy and Therapeutics, Pittsburgh, PA, USA
| | - Andjela T Drincic
- University of Nebraska Medical Center, Endocrinology & Metabolism, Omaha, NE, USA
| | - Irl B Hirsch
- University of Washington Diabetes Institute, Seattle, WA, USA
| | - Anton Luger
- Medical University and General Hospital of Vienna, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marie E McDonnell
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology Diabetes and Hypertension, Boston, MA, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Claire Pegg
- Diabetes Patient Advocacy Coalition, Tampa, FL, USA
| | - Robert J Rushakoff
- University of California, San Francisco, Department of Medicine, Division of Endocrinology and Metabolism, San Francisco, CA, USA
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12
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Kandil I, Keely E. Glucocorticoid-Induced Hyperglycemia in Oncologic Outpatients: A Narrative Review Using the Quadruple Aim Framework. Can J Diabetes 2022; 46:S1499-2671(22)00023-5. [PMID: 36055914 DOI: 10.1016/j.jcjd.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/04/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
Abstract
Glucocorticoids are a central part of cancer treatment protocols. Their use in patients receiving chemotherapy increases patient risk of hyperglycemia and associated adverse outcomes. Despite this, there have been few published protocols that guide the management of this patient group. In this narrative review, we use the quadruple aim as a framework to evaluate the current literature, including interventions, on glucocorticoid-induced hyperglycemia in patients receiving oncologic treatment, with a focus on the outpatient setting. Findings were drawn from published review articles, observational studies, qualitative reports and costing data. Results were synthesized using the framework's 4 dimensions of care: population health, provider experience, patient experience and cost. Prospective studies proposing an intervention on oncologic patients receiving glucocorticoids were identified as intervention studies. Management of glucocorticoid-induced hyperglycemia in oncologic patients is a complex problem with no published interventions addressing all components of the quadruple aim. Most evidence on this population is based on retrospective studies. Six prospective intervention studies were identified and highlighted in this review, and only 2 were exclusively in the outpatient context. Challenges included lack of standardization in screening strategies, paucity of interventions that have examined impact on patient and provider experience. There is limited evaluation of the impact of interventions targeting glycemic control on clinical outcomes and cost of care delivery, especially in the outpatient context. We propose a conceptual framework for evaluation of quality improvement programs. Management of glucocorticoid-induced hyperglycemia in the outpatient setting is complex and requires well-designed intervention studies evaluated across the quadruple aim.
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Affiliation(s)
- Ihab Kandil
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada.
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13
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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14
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Kopanz J, Lichtenegger KM, Sendlhofer G, Semlitsch B, Cuder G, Pak A, Pieber TR, Tax C, Brunner G, Plank J. Limited Documentation and Treatment Quality of Glycemic Inpatient Care in Relation to Structural Deficits of Heterogeneous Insulin Charts at a Large University Hospital. J Patient Saf 2021; 17:e631-e636. [PMID: 29432336 DOI: 10.1097/pts.0000000000000465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Insulin charts represent a key component in the inpatient glycemic management process. The aim was to evaluate the quality of structure, documentation, and treatment of diabetic inpatient care to design a new standardized insulin chart for a large university hospital setting. METHODS Historically grown blank insulin charts in use at 39 general wards were collected and evaluated for quality structure features. Documentation and treatment quality were evaluated in a consecutive snapshot audit of filled-in charts. The primary end point was the percentage of charts with any medication error. RESULTS Overall, 20 different blank insulin charts with variable designs and significant structural deficits were identified. A medication error occurred in 55% of the 102 audited filled-in insulin charts, consisting of prescription and management errors in 48% and 16%, respectively. Charts of insulin-treated patients had more medication errors relative to patients treated with oral medication (P < 0.01). Chart design did support neither clinical authorization of individual insulin prescription (10%), nor insulin administration confirmed by nurses' signature (25%), nor treatment of hypoglycemia (0%), which resulted in a reduced documentation and treatment quality in clinical practice 7%, 30%, 25%, respectively. CONCLUSIONS A multitude of charts with variable design characteristics and structural deficits were in use across the inpatient wards. More than half of the inpatients had a chart displaying a medication error. Lack of structure quality features of the charts had an impact on documentation and treatment quality. Based on identified deficits and international standards, a new insulin chart was developed to overcome these quality hurdles.
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Affiliation(s)
- Julia Kopanz
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Katharina M Lichtenegger
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | | | - Barbara Semlitsch
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Gerald Cuder
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Andreas Pak
- Department of Controlling, University Hospital Graz
| | - Thomas R Pieber
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Christa Tax
- Board of Directors, University Hospital Graz
| | | | - Johannes Plank
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital Graz, Austria
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15
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Cheng YC, Guerra Y, Morkos M, Tahsin B, Onyenwenyi C, Fogg L, Fogelfeld L. Insulin management in hospitalized patients with diabetes mellitus on high-dose glucocorticoids: Management of steroid-exacerbated hyperglycemia. PLoS One 2021; 16:e0256682. [PMID: 34529703 PMCID: PMC8445406 DOI: 10.1371/journal.pone.0256682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background Glucocorticoid (GC)-exacerbated hyperglycemia is prevalent in hospitalized patients with diabetes mellitus (DM) but evidence-based insulin guidelines in inpatient settings are lacking. Methods and findings Retrospective cohort study with capillary blood glucose (CBG) readings and insulin use, dosed with 50% basal (glargine)-50% bolus (lispro) insulin, analyzed in hospitalized patients with insulin-treated DM given GC and matched controls without GC (n = 131 pairs). GC group (median daily prednisone-equivalent dose: 53.36 mg (IQR 30.00, 80.04)) had greatest CBG differences compared to controls at dinner (254±69 vs. 184±63 mg/dL, P<0.001) and bedtime (260±72 vs. 182±55 mg/dL, P<0.001). In GC group, dinner CBG was 30% higher than lunch (254±69 vs. 199±77 mg/dL, P<0.001) when similar lispro to controls given at lunch. Bedtime CBG not different from dinner when 20% more lispro given at dinner (0.12 units/kg (IQR 0.08, 0.17) vs. 0.10 units/kg (0.06, 0.14), P<0.01). Despite receiving more lispro, bedtime hypoglycemic events were lower in GC group (0.0% vs. 5.9%, P = 0.03). Conclusions Since equal bolus doses inadequately treat large dinner and bedtime GC-exacerbated glycemic excursions, initiating higher bolus insulin at lunch and dinner with additional enhanced GC-specific insulin supplemental scale may be needed as initial insulin doses in setting of high-dose GC.
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Affiliation(s)
- Yu-Chien Cheng
- Division of Endocrinology, John H. Stroger. Jr. Hospital of Cook County, Chicago, Illinois, United States of America
- Section of Endocrinology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Yannis Guerra
- Division of Endocrinology, John H. Stroger. Jr. Hospital of Cook County, Chicago, Illinois, United States of America
- Section of Endocrinology, Rush University Medical Center, Chicago, Illinois, United States of America
- * E-mail:
| | - Michael Morkos
- Division of Endocrinology, John H. Stroger. Jr. Hospital of Cook County, Chicago, Illinois, United States of America
- Section of Endocrinology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Bettina Tahsin
- Division of Endocrinology, John H. Stroger. Jr. Hospital of Cook County, Chicago, Illinois, United States of America
- Section of Endocrinology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Chioma Onyenwenyi
- Division of Endocrinology, John H. Stroger. Jr. Hospital of Cook County, Chicago, Illinois, United States of America
- Section of Endocrinology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Louis Fogg
- Department of Community Nursing, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Leon Fogelfeld
- Division of Endocrinology, John H. Stroger. Jr. Hospital of Cook County, Chicago, Illinois, United States of America
- Section of Endocrinology, Rush University Medical Center, Chicago, Illinois, United States of America
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16
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HOKENEK NM, AK R. The effect of blood gas analysis and Charlson comorbidity index evaluation on the prediction of hospitalization period in patients with diabetic hyperglycemic crisis. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.953157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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17
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Vaezi AA, Sotoudeh A, Namiranian N, Ardakani MF, Zareipour M. Facilitators and barriers of herbal medicine use in diabetic patients: A qualitative study. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:303. [PMID: 34667803 PMCID: PMC8459873 DOI: 10.4103/jehp.jehp_1451_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND In several countries such as Iran, the use of complementary and alternative medical products like herbal medicine is growing. There is, however, a lack of research on the prospects of herbal medicine patrons regarding facilitators and herbal medicine use barriers. The aim of this study was to explain the facilitators and the barriers of herbal medicine use in type 2 diabetes mellitus (T2DM) patients. MATERIALS AND METHODS Qualitative one-to-one in-depth interviews were conducted with patients with T2DM from the Yazd Diabetes Research Center, using a semi-structured guide. For the recruitment of T2DM participants who used herbal medicine beside conventional medicine, purposeful sampling was used. Analysis of the data was carried out using the steps proposed by Graneheim and Landman strategies. RESULTS Sixteen patients were interviewed. There were 2 subjects (facilitators and barriers herbal medicine use), 8 categories, and 89 initial codes. The facilitators included individual preferences, preparation skills, and family support and the factors obstructing the use of herbal medicine included insufficient skills about preparing, lack of easy access to consumption, insufficient of efficacy of herbal medicine, and negative properties of herbal medicine and taking time in preparing herbal medicine. CONCLUSION Although some people use herbal medicine, the interest in use of herbal medicine is limited because of inadequate awareness of the impact and usage them. Therefore, the use of effective strategy in the integration of herbal remedies with conventional medicine can promote well-being of patients.
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Affiliation(s)
- Ali Akbar Vaezi
- Department of Nursing, School of Nursing and Midwifery, Research Center for Nursing and Midwifery Care in Family Health, Shahid Sadughi University of Medical Science, Yazd, Iran
| | - Ahmad Sotoudeh
- Department of Health Education and Promotion, School of Public Health, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Nasim Namiranian
- Diabetes Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Moradali Zareipour
- Health System Research Unit, Health Center of Urmia, Urmia University of Medical Sciences, Urmia, Iran
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18
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Abstract
The endocrine hospitalist and inpatient diabetes management team increases access to endocrinology consultations and improves glycemic control and quality metrics such as length of stay and hospital readmission. Enhanced glycemic care is needed in both academic and community hospital settings. Endocrine fellowship programs should implement endocrine hospitalist rotations with emphasis on training endocrine fellows to deliver fast-paced inpatient endocrine care. Entrepreneurship, innovation, and a "start-up" culture within the field of Endocrinology should be encouraged and supported by healthcare systems.
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Affiliation(s)
- Mihail Zilbermint
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University Carey Business School, Baltimore, MD, USA
- Mihail Zilbermint, MD, FACE, Johns Hopkins Community Physicians at Suburban Hospital, 8600 Old Georgetown Road, 6th Floor Endocrinology Office, Bethesda, MD 20814, USA.
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19
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Eccles-Smith J, Puri G, Hinton N, Cutmore C, Porter K, Dermedgoglou A, Donovan P. Access to inpatient diabetes resources: hospital characteristics from the inaugural Queensland Inpatient Diabetes Survey. Intern Med J 2021; 52:1950-1956. [PMID: 34145712 DOI: 10.1111/imj.15433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/28/2022]
Abstract
AIMS To establish the prevalence of diabetes in Queensland hospitals and assess the availability of specialised diabetes staff, educational resources and policies for inpatient diabetes management, including assessing equity of access to these resources. METHODS The hospital capacity, prevalence of diabetes, diabetes-related resources and the availability of diabetes-related guidelines were assessed in 25 hospitals medical, surgical, mental health, high-dependency and intensive care wards of level 2-6 public hospitals across Queensland. Diabetes-dedicated staffing measured in full-time equivalents, care delivery resources, access to educational resources, standard policies and procedures for care were assessed. RESULTS Twenty-five hospitals included 4265 occupied beds. The median prevalence of diabetes was 22.9% (IQR 17.3-28.5%) with an average 2.9 FTE per 100 patients with diabetes (IQR 0-6.3). There was difficulty in accessing a diabetes educator in 48% (n = 12), diabetes specialist in 44% (n = 11), orthopaedic surgeon in 48% (n = 12), podiatrist in 58% (n = 14) and vascular surgeon in 64% (n = 16) of hospitals. Small hospitals had more difficulty accessing all members of the diabetes team compared to large hospitals including credentialled diabetes educators 33% (n = 4) versus 62% (n = 8) (p = 0.0001), diabetes specialists 17% (n = 2) versus 69% (n = 9) (p < 0.00001) and vascular surgeons 33% (n = 4) versus 92% (n = 12) (p < 0.000001). Diabetes-related staff education and regular nurse training was available in 40% (n = 10) of hospitals. A multi-disciplinary foot care team was available in 28% (n = 7) of hospitals. CONCLUSIONS Queensland's has a high prevalence of diabetes in hospitalised patients and they have limited and inequitable access to inpatient diabetes-related care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jade Eccles-Smith
- Royal Brisbane and Women's Hospital, Department of Endocrinology, Cnr Butterfield St and Bowen Bridge Rd, Herston, QLD, AUS 4029, Australia.,The University of Queensland Faculty of Medicine and Biological Sciences
| | - Gaurav Puri
- Cairns and Hinterland Hospital and Health Service, Department of Endocrinology, 165 The Esplanade, Cairns, QLD, AUS 4870, Australia
| | - Nicola Hinton
- Cairns and Hinterland Hospital and Health Service, Department of Endocrinology, 165 The Esplanade, Cairns, QLD, AUS 4870, Australia
| | - Clare Cutmore
- Royal Brisbane and Women's Hospital, Nutrition and Dietetics, Butterfield Street, Herston, QLD, AUS 4029, Australia
| | - Kerry Porter
- Princess Alexandra Hospital, Diabetes & Endocrinology Nurse Practitioner, 199 Ipswich Rd, Woolloongabba, QLD, AUS 4102, Australia
| | - Alexis Dermedgoglou
- Cairns and Hinterland Hospital and Health Service, Department of Endocrinology, 165 The Esplanade, Cairns, QLD, AUS 4870, Australia
| | - Peter Donovan
- The University of Queensland Faculty of Medicine and Biological Sciences.,Royal Brisbane and Women's Hospital, Director Department of Clinical Pharmacology, Cnr Butterfield St and Bowen Bridge Rd, Herston, QLD, AUS 4029, Australia
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20
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Hitchen SA, Lan NSR, Ali US, Hort AL, Larbalestier R, Yeap BB, Fegan PG. Investigating the effect of an education program on diabetes and lipid lowering medication usage following coronary artery bypass graft surgery. Intern Med J 2021; 52:1354-1365. [PMID: 34033208 DOI: 10.1111/imj.15393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/14/2021] [Accepted: 05/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Guidelines advocate multifactorial cardiovascular risk management in patients with diabetes and atherosclerotic cardiovascular disease. In hospitalised patients with diabetes following coronary artery bypass graft (CABG) we evaluated the impacts of decision-support algorithms for optimising glycaemia and lipid-lowering. We also assessed the safety of initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors near time of hospital discharge. METHODS This was a single-site, pre- and post-intervention analysis of glucose and lipid management in consecutive hospitalised patients with diabetes undergoing CABG surgery. The intervention involved education and decision-support algorithms designed by a multidisciplinary committee to guide cardiac surgery unit clinicians. RESULTS A total of 200 patients were included in the study. The pre- and post-intervention groups had similar baseline characteristics (HbA1c 7.9 ± 1.9% versus 8.1 ± 1.8%). Of 4092 blood glucose measurements the incidence of levels between 5 to 10 mmol/L was not different post-intervention (55.5% versus 57.0%, p = 0.441). Fewer endocrinology consultations occurred (59.0% versus 45.0%, p = 0.048) and rates of hypoglycaemia remained low. High-intensity statin was prescribed in >90% pre- and post-intervention although non-statin lipid-lowering agents remained <10% despite patients not achieving LDL-C targets. No 30-day readmissions for diabetic ketoacidosis occurred in patients prescribed SGLT2 inhibitors. CONCLUSION The intervention did not improve inpatient glycaemia or increase non-statin lipid-lowering prescriptions in patients with diabetes following CABG surgery but did reduce reliance on specialty input. Initiation of SGLT2 inhibitor therapy near time of hospital discharge was not associated with safety concerns. Alternative interventions or strategies are required to optimise glycaemia and non-statin lipid-lowering therapy prescribing in this setting. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sarah A Hitchen
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Department of Pharmacy, Fiona Stanley Hospital, Western Australia, Australia
| | - Nick S R Lan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Department of Cardiology, Fiona Stanley Hospital, Western Australia.,Medical School, The University of Western Australia, Western Australia, Australia
| | - Umar S Ali
- Medical School, The University of Western Australia, Western Australia, Australia.,Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Western Australia, Australia
| | - Adam L Hort
- Department of Pharmacy, Fiona Stanley Hospital, Western Australia, Australia
| | - R Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Western Australia, Australia
| | - Bu B Yeap
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Medical School, The University of Western Australia, Western Australia, Australia
| | - P Gerry Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Medical School, Curtin University, Western Australia, Australia
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21
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Libiseller A, Lichtenegger KM, de Campo A, Wiesinger T, Cuder G, Donsa K, Höll B, Beck P, Plank J, Schippinger W, Pieber TR. Diabetes Management According to Health Status in Older Adults with Type 2 Diabetes Staying in Geriatric Care Facilities. J Diabetes Sci Technol 2021; 15:615-621. [PMID: 32054294 PMCID: PMC8120046 DOI: 10.1177/1932296820905827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND About 25% of adults >70 years suffer from type 2 diabetes. Due to the heterogeneity of the geriatric population, guidelines emphasize the need to individualize glycemic goals and simplify treatment strategies with the main focus of avoiding hypoglycemia. The aim of this study was to assess glycemic control in patients with type 2 diabetes in geriatric care facilities based on their individual health status. METHODS 170 medical records of older adults with type 2 diabetes in geriatric care facilities were retrospectively assessed (64.7% female, age 80 ± 9 years; glycated hemoglobin 6.8% ± 3.6% [51 ± 16 mmol/mol]; body mass index 27.9 ± 5.8 kg/m2). Based on the individual health status, patients were allocated to three groups (healthy n = 27, complex n = 86, and poor n = 57). RESULTS The overall blood glucose (BG) value was highest in the poor health group with 188 ± 47 mg/dL (poor) vs 167 ± 42 mg/dL (complex) vs 150 ± 34 mg/dL (healthy). BG values of 1.6% (poor) vs 2.8% (complex) vs 1.5% (healthy) of patients were below 90 mg/dL. 36.8% (poor) vs 23.4% (complex) vs 18.5% (healthy) of patients received insulin as the main diabetes therapy, but of these only 14.3% (poor) vs 20% (complex) vs 40% (healthy) were treated with basal insulin. CONCLUSIONS Overall, BG values were higher in the poor and complex health group. There were a few low BG values in all groups. Although recommended by international guidelines, basal insulin therapy with its low complexity and low hypoglycemic risk is still underused, especially in the poor health group. Therefore, simplification of diabetes therapy should be considered further.
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Affiliation(s)
- Angela Libiseller
- Division of Endocrinology and
Diabetology, Medical University of Graz, Austria
| | | | | | | | - Gerald Cuder
- Division of Endocrinology and
Diabetology, Medical University of Graz, Austria
| | - Klaus Donsa
- JOANNEUM RESEARCH
ForschungsgesellschaftmbH, Graz, Steiermark, Austria
| | - Bernhard Höll
- JOANNEUM RESEARCH
ForschungsgesellschaftmbH, Graz, Steiermark, Austria
| | - Peter Beck
- JOANNEUM RESEARCH
ForschungsgesellschaftmbH, Graz, Steiermark, Austria
| | - Johannes Plank
- Division of Endocrinology and
Diabetology, Medical University of Graz, Austria
| | | | - Thomas R. Pieber
- Division of Endocrinology and
Diabetology, Medical University of Graz, Austria
- JOANNEUM RESEARCH
ForschungsgesellschaftmbH, Graz, Steiermark, Austria
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22
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Hitchen SA, Lan NSR, Hort AL, Rankin JM, Fegan PG, Yeap BB. Managing inpatient hyperglycaemia and initiating sodium-glucose cotransporter 2 inhibitor therapy in the setting of diabetes and acute coronary syndrome. Intern Med J 2021; 51:428-432. [PMID: 33738945 DOI: 10.1111/imj.15245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 09/17/2020] [Indexed: 12/01/2022]
Abstract
We previously showed that implementing algorithms for managing diabetes in acute coronary syndrome was associated with improved inpatient glycaemic control and increased sodium-glucose cotransporter 2 (SGLT2) inhibitor prescriptions. The present study performed 1 year later found that inpatient hyperglycaemia had relapsed to pre-intervention rates, although SGLT2 inhibitor prescriptions remained increased. We discuss the challenges of improving inpatient glycaemic control.
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Affiliation(s)
- Sarah A Hitchen
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Pharmacy, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Nick S R Lan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Adam L Hort
- Department of Pharmacy, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - P Gerry Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Bu B Yeap
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
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23
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Lichtenegger KM, Aberer F, Tuca AC, Donsa K, Höll B, Schaupp L, Plank J, Beck P, Fruhwald FM, Kamolz LP, Pieber TR, Mader JK. Safe and Sufficient Glycemic Control by Using a Digital Clinical Decision Support System for Patients With Type 2 Diabetes in a Routine Setting on General Hospital Wards. J Diabetes Sci Technol 2021; 15:231-235. [PMID: 32914640 PMCID: PMC8256070 DOI: 10.1177/1932296820955243] [Citation(s) in RCA: 3] [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] [Indexed: 11/15/2022]
Abstract
The aim was to investigate the applicability of a clinical decision support system in a real-world inpatient setting for patients with type 2 diabetes on general hospital wards.A total of 150 patients with type 2 diabetes requiring subcutaneous insulin therapy were treated with basal-bolus insulin therapy guided by a decision support system (GlucoTab) providing automated workflow tasks and suggestions for insulin dosing to health care professionals.By using the system, a mean daily blood glucose (BG) of 159 ± 32 mg/dL was achieved. 68.8% of measurements were in the target range (70 to <180 mg/dL). The percentage of BG values <40, <70, and ≥300 mg/dL was 0.02%, 2.2%, and 2.3%, respectively. Health care professionals' adherence to suggested insulin doses and workflow tasks was high (>93% and 91%, respectively).The decision support system facilitates safe and efficacious inpatient diabetes care by standardizing treatment workflow and providing decision support for basal-bolus insulin dosing.
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Affiliation(s)
- Katharina M. Lichtenegger
- Department of Internal Medicine, Division of
Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Felix Aberer
- Department of Internal Medicine, Division of
Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Alexandru C. Tuca
- Department of Surgery, Division of Plastic,
Aesthetic and Reconstructive Surgery, Medical University of Graz, Austria
| | - Klaus Donsa
- Joanneum Research GmbH, HEALTH, Institute for
Biomedicine and Health Sciences, Austria
| | - Bernhard Höll
- Joanneum Research GmbH, HEALTH, Institute for
Biomedicine and Health Sciences, Austria
- decide Clinical Software GmbH, Austria
| | - Lukas Schaupp
- Department of Internal Medicine, Division of
Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Johannes Plank
- Department of Internal Medicine, Division of
Gastroenterology and Hepatology, Medical University of Graz, Austria
| | - Peter Beck
- Joanneum Research GmbH, HEALTH, Institute for
Biomedicine and Health Sciences, Austria
- decide Clinical Software GmbH, Austria
- Peter Beck, MSc, PhD, decide Clinical Software GmbH,
Neue Stiftingtalstraße 2, Graz A-8010, Austria.
| | - Friedrich M Fruhwald
- Department of Internal Medicine, Division of
Cardiology, Medical University of Graz, Austria
| | - Lars-Peter Kamolz
- Department of Surgery, Division of Plastic,
Aesthetic and Reconstructive Surgery, Medical University of Graz, Austria
| | - Thomas R. Pieber
- Department of Internal Medicine, Division of
Endocrinology and Diabetology, Medical University of Graz, Austria
- Joanneum Research GmbH, HEALTH, Institute for
Biomedicine and Health Sciences, Austria
| | - Julia K. Mader
- Department of Internal Medicine, Division of
Endocrinology and Diabetology, Medical University of Graz, Austria
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Kopanz J, Lichtenegger KM, Koenig C, Libiseller A, Mader JK, Donsa K, Truskaller T, Bauer N, Hahn B, Sendlhofer G, Beck P, Höll B, Sinner F, Feichtner F, Pieber TR. Electronic Diabetes Management System Replaces Paper Insulin Chart: Improved Quality in Diabetes Inpatient Care Processes Due to Digitalization. J Diabetes Sci Technol 2021; 15:222-230. [PMID: 32935559 PMCID: PMC8256067 DOI: 10.1177/1932296820957043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND GlucoTab, an electronic diabetes management system (eDMS), supports healthcare professionals (HCPs) in inpatient blood glucose (BG) management at point-of-care and was implemented for the first time under routine conditions in a regional hospital to replace the paper insulin chart. METHOD To investigate quality of the eDMS for inpatients with type 2 diabetes mellitus a monocentric retrospective before-after evaluation was conducted. We compared documentation possibilities by assessing a blank paper chart vs the eDMS user interface. Further quality aspects were compared by assessing filled-in paper charts (n = 106) vs filled-in eDMS documentation (n = 241). HCPs (n = 59) were interviewed regarding eDMS satisfaction. RESULTS The eDMS represented an improvement of documentation possibilities by offering a more structured and comprehensive user interface compared to the blank paper chart. The number of good diabetes days averaged to a median value of four days in both groups (paper chart: 4.38 [0-7] vs eDMS: 4.38 [0-7] days). Median daily BG was 170 (117-297) mg/dL vs 168 (86-286) mg/dL and median fasting BG was 152 (95-285) mg/dL vs 145 (69-333) mg/dL, and 0.1% vs 0.4% BG values <54 mg/dL were documented. Diabetes documentation quality improved when using eDMS, for example, documentation of ordered BG measurement frequency (1% vs 100%) and ordered BG targets (0% vs 100%). HCPs stated that by using eDMS errors could be prevented (74%), and digital support of work processes was completed (77%). Time saving was noted by 8 out of 11 HCPs and estimated at 10-15 minutes per patient day by two HCPs. CONCLUSIONS The eDMS completely replaced the paper chart, showed comparable glycemic control, was positively accepted by HCPs, and is suitable for inpatient diabetes management.
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Affiliation(s)
- Julia Kopanz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Katharina M Lichtenegger
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Constanze Koenig
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Angela Libiseller
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Julia K Mader
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Klaus Donsa
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Thomas Truskaller
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Norbert Bauer
- Department of Internal Medicine, LKH Hartberg, Austria
| | | | - Gerald Sendlhofer
- Department for Surgery, Research Unit for Safety in Health, Division for Plastic, Aesthetic and Reconstructive Surgery, Medical University of Graz, Austria
| | - Peter Beck
- Decide Clinical Software GmbH, Graz, Austria
| | | | - Frank Sinner
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Franz Feichtner
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Thomas R Pieber
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
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Kopanz J, Sendlhofer G, Lichtenegger K, Semlitsch B, Riedl R, Pieber TR, Tax C, Brunner G, Plank J. Evaluation of an implemented new insulin chart to improve quality and safety of diabetes care in a large university hospital: a follow-up study. BMJ Open 2021; 11:e041298. [PMID: 33500281 PMCID: PMC7839871 DOI: 10.1136/bmjopen-2020-041298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To evaluate structure, documentation, treatment quality of a new implemented standardised insulin chart in adult medical inpatient wards at a university hospital. DESIGN A before-after study (3 to 5 months after implementation) was used to compare the quality of old versus new insulin charts. SETTING University Hospital Graz, Austria. PARTICIPANTS Healthcare professionals (n=237) were questioned regarding structure quality of blank insulin charts. INTERVENTIONS A new standardised insulin chart was implemented and healthcare professionals were trained regarding features of this chart. Data from insulinised inpatients were evaluated regarding documentation and treatment quality of filled-in insulin charts (n=108 old insulin charts vs n=100 new insulin charts). MAIN OUTCOMES AND MEASURES The primary endpoint was documentation error for insulin administration. RESULTS Healthcare professionals reported an improved structure quality of the new insulin chart with a Likert type response scale increase in all nine items. Documentation errors for insulin administration (primary endpoint) occurred more often on old than new insulin charts (77% vs 5%, p<0.001). Documentation errors for insulin prescription were more frequent on old insulin charts (100% vs 42%) whereas documentation errors for insulin management rarely occurred in any group (10% vs 8%). Patients of both chart evaluation groups (age: 71±11 vs 71±12 years, 47% vs 42% women, 75% vs 87% type 2 diabetes for old vs new charts, respectively) had a mean of 4±2 good diabetes days. Overall, 26 vs 18 hypoglycaemic episodes (blood glucose (BG) <4.0 mmol/L (72 mg/dL), p=0.28), including 7 vs 2 severe hypoglycaemic episodes (BG <3.0 mmol/L (54 mg/dL), p=0.17) were documented on old versus new insulin charts. CONCLUSIONS The implementation of a structured documentation form together with training measures for healthcare professionals led to less documentation errors and safe management of glycaemic control in hospitalised patients in a short time follow-up. A rollout at further medical wards is recommended, and sustainability in the long-term has to be demonstrated.
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Affiliation(s)
- Julia Kopanz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Executive Department for Quality and Risk Management, University Hospital of Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Katharina Lichtenegger
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Barbara Semlitsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christa Tax
- Chief Nursing Director, University Hospital Graz, Graz, Styria, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Chief Medical Director, University Hospital Graz, Graz, Styria, Austria
| | - Johannes Plank
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Sheahan KH, Atherly A, Dayman C, Schnure J. The impact of diabetology consultations on length of stay in hospitalized patients with diabetes. Endocrinol Diabetes Metab 2021; 4:e00199. [PMID: 33532624 PMCID: PMC7831220 DOI: 10.1002/edm2.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/01/2020] [Accepted: 10/18/2020] [Indexed: 12/26/2022] Open
Abstract
Introduction Both hyperglycaemia and hypoglycaemia in hospitalized patients have been shown to be associated with a longer length of stay, higher readmission rates, and higher rates of morbidity and mortality. With 25%-30% of all hospitalized patients carrying a diagnosis of diabetes, it is important to optimize glycaemic control. Current guidelines for care of inpatients with diabetes now suggest consulting a specialized diabetes team for all patients when possible. Aim This study was a retrospective cohort study to evaluate the impact of an inpatient diabetology consult within 48 hours of admission on patients' length of stay. Methods All patients admitted to the general medicine service between 2013 and 2018 with a diagnosis of diabetes in their medical record were included, which consisted of 11 477 inpatient stays. We looked at the effect of an inpatient diabetology consultation within the first 48 hours on length of stay, complications and 30-day readmission rates. Results We found that patients whose care included a diabetology consult within 48 hours of admission had a statistically significant shorter length of stay by 1.56 days compared to the remainder of the group. There was no difference in complications or 30-day readmission rates between the groups. Conclusion Among general medicine patients with a diagnosis of diabetes, timely diabetology consultations reduced patients' length of stay and have the potential to improve their care and lessen the economic impact.
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Affiliation(s)
- Kelsey H. Sheahan
- Division of Endocrinology and DiabetesLarner College of Medicine at The University of VermontBurlingtonVTUSA
| | - Adam Atherly
- Center for Health Services ResearchLarner College of Medicine at The University of VermontBurlingtonVTUSA
| | - Caitlyn Dayman
- Center for Health Services ResearchLarner College of Medicine at The University of VermontBurlingtonVTUSA
| | - Joel Schnure
- Division of Endocrinology and DiabetesLarner College of Medicine at The University of VermontBurlingtonVTUSA
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Chen P, Chen L, Zhao X, Sun Q. The Association of Mean Plasma Glucose and In hospital Death Proportion: A Retrospective, Cohort Study of 162,169 In-Patient Data. Int J Endocrinol 2021; 2021:1513683. [PMID: 33531898 PMCID: PMC7834774 DOI: 10.1155/2021/1513683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/12/2020] [Accepted: 12/21/2020] [Indexed: 01/08/2023] Open
Abstract
AIMS To investigate the association between mean plasma glucose and inhospital death proportion. METHODS We retrospectively collected 162,169 inpatient data in Huashan Hospital from January 2012 to December 2015. Mean plasma glucose was calculated and considered as the average glycemia control during hospitalization. Patients were stratified into six groups according to mean plasma glucose. Nonlinear regression was performed to determine the associations between mean plasma glucose and inhospital death proportion, medical cost, and length of stay. Multivariate logistic regressions were performed to evaluate the relationship of mean plasma glucose and outcomes controlling for confounders including age, gender, and others. Subgroup analyses were performed on basis of whether they were surgical patients, ICU patients, patients with diabetes, or others. RESULTS Of the 162,169 hospitalized participants, 53.32% were male and 989 died during hospitalization. Nonlinear regression showed there were positive and significant associations between mean plasma glucose and death proportion, medical cost, and length of stay (P < 0.001 for all). Multivariate logistic regressions showed that, compared with group B, a statistically significant association between mean plasma glucose and predicted outcome was apparent, with the odds ratios (95% confidence interval) of 5.79 (3.51-9.55), 2.85 (2.40-3.38), 6.29 (5.24-7.54), 9.34 (7.51-11.62), and 23.52 (16.64-33.26), for group A, group C, group D, group E, and group F, respectively. There was a U-shaped association between mean plasma glucose and death proportion. Subgroup analyses showed similar associations between mean plasma glucose and death proportion, medical cost, and length of stay as in the whole sample. CONCLUSIONS There was a U-curve association between mean plasma glucose with inhospital death proportion. Mean plasma glucose was associated positively with medical cost and length of stay.
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Affiliation(s)
- Peili Chen
- Department of Endocrinology, Huashan Hospital Fudan University, Shanghai, China
| | - Lili Chen
- Department of Endocrinology, Huashan Hospital Fudan University, Shanghai, China
| | - Xiaolong Zhao
- Department of Endocrinology, Huashan Hospital Fudan University, Shanghai, China
| | - Quanya Sun
- Department of Endocrinology, Huashan Hospital Fudan University, Shanghai, China
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Jones JML, Feitosa ACR, Hita MC, Fonseca EM, Pato RB, Toyoshima MTK. Medical software applications for in-hospital insulin therapy: A systematic review. Digit Health 2020; 6:2055207620983120. [PMID: 34104463 PMCID: PMC8162202 DOI: 10.1177/2055207620983120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
Background In-hospital hyperglycemia (HH) is frequent and related to higher morbidity and mortality. Despite the benefits of HH treatment, glycemic control is often poor and neglected. The use of health applications to support diagnosis and therapy is now incorporated into medical practice. Medical applications for inpatient glycemic management have potential to standardize this handling by the nonspecialist physician. However, related studies are scarce. We aim to evaluate the efficacy in inpatient glycemic control parameters of medical software applications in non-critical care settings. Methods This systematic review on in-hospital insulin applications was performed according to PRISMA guidelines. Data were extracted in triplicate and methodological quality was verified. Specific outcomes of interest were glycemic control efficacy, hypoglycemia risk, length of in-hospital stay, integration with the electronic medical record and healthcare staff acceptance. Results Among the 573 articles initially identified and subsequent revision of the references of each one, seven studies involving six applications were eligible for the review. A better glycemic control was reported with the use of most in-hospital insulin applications in the studies evaluated, but there was no mention of the time to reach the glycemic goal. The risk of hypoglycemia was low. Different reasons influenced the varied acceptance of the use of applications among health professionals. Conclusion The six applications of inpatient insulin therapy in a non-critical care environment proved to be useful and safe compared to the usual management. Medical apps are tools that can help improve the quality of patient care.
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Affiliation(s)
| | | | - Malena Costa Hita
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | | | | | - Marcos Tadashi Kakitani Toyoshima
- Oncoendocrinology service of Instituto do Cancer do Estado de Sao Paulo Octávio Frias de Oliveira, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Hospital Medicine service, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Clinical Prediction Tool To Identify Adults With Type 2 Diabetes at Risk for Persistent Adverse Glycemia in Hospital. Can J Diabetes 2020; 45:114-121.e3. [PMID: 33011129 DOI: 10.1016/j.jcjd.2020.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/06/2020] [Accepted: 06/03/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Given the high incidence of hyperglycemia and hypoglycemia in hospital and the lack of prediction tools for this problem, we developed a clinical tool to assist early identification of individuals at risk for persistent adverse glycemia (AG) in hospital. METHODS We analyzed a cohort of 594 consecutive adult inpatients with type 2 diabetes. We identified clinical factors available early in the admission course that were associated with persistent AG (defined as ≥2 days with capillary glucose <4 or >15 mmol/L during admission). A prediction model for persistent AG was constructed using logistic regression and internal validation was performed using a split-sample approach. RESULTS Persistent AG occurred in 153 (26%) of inpatients, and was associated with admission dysglycemia (odds ratio [OR], 3.65), glycated hemoglobin ≥8.1% (OR, 5.08), glucose-lowering treatment regimen containing sulfonylurea (OR, 3.50) or insulin (OR, 4.22), glucocorticoid medication treatment (OR, 2.27), Charlson Comorbidity Index score and the number of observed days. An early-identification prediction tool, based on clinical factors reliably available at admission (admission dysglycemia, glycated hemoglobin, glucose-lowering regimen and glucocorticoid treatment), could accurately predict persistent AG (receiver-operating characteristic area under curve = 0.806), and, at the optimal cutoff, the sensitivity, specificity and positive predictive value were 84%, 66% and 53%, respectively. CONCLUSIONS A clinical prediction tool based on clinical risk factors available at admission to hospital identified patients at increased risk for persistent AG and could assist early targeted management by inpatient diabetes teams.
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Perioperative Management of Pediatric Patients With Type 1 Diabetes Mellitus, Updated Recommendations for Anesthesiologists. Anesth Analg 2020; 130:821-827. [DOI: 10.1213/ane.0000000000004491] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Ketz JM, Yeh EJ, Suri S. Collaboration of Hospital Pharmacists and Hospitalists to Address Glycemic Control of General Medicine Patients: Implementation of a Pilot Inpatient Diabetes Management Program. Clin Diabetes 2020; 38:71-77. [PMID: 31975754 PMCID: PMC6969653 DOI: 10.2337/cd19-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study examined the clinical benefits of a collaborative pharmacist-physician inpatient diabetes management program that included daily blood glucose assessment and the recommendation and implementation of American Diabetes Association-recommended insulin regimens.
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Affiliation(s)
- Jeffrey M Ketz
- Cleveland Clinic, Cleveland, OH; E.J.Y. is now affiliated with Amgen, Inc., Thousand Oaks, CA
| | - Eric J Yeh
- Cleveland Clinic, Cleveland, OH; E.J.Y. is now affiliated with Amgen, Inc., Thousand Oaks, CA
| | - Sanjeev Suri
- Cleveland Clinic, Cleveland, OH; E.J.Y. is now affiliated with Amgen, Inc., Thousand Oaks, CA
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Garg R. TOO MUCH CONFIDENCE, TOO LITTLE KNOWLEDGE. Endocr Pract 2020; 25:1360-1361. [PMID: 31891548 DOI: 10.4158/ep-2019-0378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Lan NSR, Fegan PG, Rankin JM, Bell DA, Watts GF, Yeap BB. Implementing simple algorithms to improve glucose and lipid management in people with diabetes and acute coronary syndrome. Diabet Med 2019; 36:1643-1651. [PMID: 31365761 DOI: 10.1111/dme.14095] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 12/25/2022]
Abstract
AIM Diabetes mellitus is associated with increased risk of adverse outcomes following acute coronary syndrome. Translating evidence-based recommendations into practice is necessary to improve outcomes. We evaluated whether implementing algorithms to guide inpatient care improved glycaemic control, and increased use of sodium-glucose co-transporter 2 (SGLT2) inhibitors and lipid-lowering medication in a tertiary cardiac unit. METHOD A 3-month audit (phase 1) was conducted to evaluate hyperglycaemia and dyslipidaemia management, and medication prescriptions. Consecutive people with diabetes admitted for acute coronary syndrome were prospectively identified. Target blood glucose level was defined as 5-10 mmol/l. A multidisciplinary committee designed and implemented decision-support algorithms plus education. A 3-month post-implementation audit (phase 2) was conducted. RESULTS There were 104 people in phase 1 and 101 in phase 2, with similar characteristics [HbA1c 64 ± 20 mmol/mol vs. 61 ± 21 mmol/mol (8.0 ± 1.8% vs. 7.8 ± 1.9%]. Post implementation, the incidence of blood glucose levels > 10 mmol/l was lower [phase 1: 46.4% vs. phase 2: 31.8%, rate ratio (RR) = 0.77, 95% confidence intervals (CI) 0.60-0.98; P = 0.031], without a difference in blood glucose levels < 5mmol/l (phase 1: 4.9% vs. phase 2: 4.5%, RR = 1.20, 95% CI 0.70-2.08; P = 0.506). SGLT2 inhibitor prescriptions increased significantly (baseline to discharge: 12.5% to 15.4% vs. 7.9% to 24.8%; P = 0.007) but high-intensity statin prescriptions did not (baseline to discharge: 35.6% to 72.1% vs. 40.6% to 85.1%; P = 0.074). Prescription rates of non-statin lipid-lowering medications were not significantly increased. CONCLUSIONS Implementing decision-support algorithms was associated with improved inpatient glycaemic control and increased use of cardioprotective therapies at discharge in people with diabetes and acute coronary syndrome.
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Affiliation(s)
- N S R Lan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - P G Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - J M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - D A Bell
- Medical School, The University of Western Australia, Crawley, WA, Australia
- Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, WA, Australia
- Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth and Fiona Stanley Hospitals, Perth, WA, Australia
| | - G F Watts
- Medical School, The University of Western Australia, Crawley, WA, Australia
- Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, WA, Australia
| | - B B Yeap
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, The University of Western Australia, Crawley, WA, Australia
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User Centered Design to Improve Information Exchange in Diabetes Care Through eHealth : Results from a Small Scale Exploratory Study. J Med Syst 2019; 44:2. [PMID: 31741069 DOI: 10.1007/s10916-019-1472-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
Heterogeneity of people with diabetes makes maintaining blood glucose control and achieving therapy adherence a challenge. It is fundamental that patients get actively involved in the management of the disease in their living environments. The objective of this paper is to evaluate the use and acceptance of a self-management system for diabetes developed with User Centered Design Principles in community settings. Persons with diabetes and health professionals were involved the design, development and evaluation of the self-management system; which comprised three iterative cycles: scenario definition, user archetype definition and system development. A comprehensive system was developed integrating modules for the management of blood glucose levels, medication, food intake habits, physical activity, diabetes education and messaging. The system was adapted for two types of principal users (personas): Type 1 Diabetes user and Type 2 Diabetes user. The system was evaluated by assessing the use, the compliance, the attractiveness and perceived usefulness in a multicenter randomized pilot study involving 20 patients and 24 treating professionals for a period of four weeks. Usage and compliance of the co-designed system was compared during the first and the last two weeks of the study, showing a significantly improved behaviour of patients towards the system for each of the modules. This resulted in a successful adoption by both type of personas. Only the medication module showed a significantly different use and compliance (p= 0.01) which can be explained by the different therapeutic course of the two types of diabetes. The involvement of patients to make their own decisions and choices form design stages was key for the adoption of a self-management system for diabetes.
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Abstract
PURPOSE OF REVIEW The goal of this review is to summarize information about insulin dosing software and calculators used as computerized decision support systems or electronic glucose management systems (eGMS). These are used for hospitalized, insulin-treated patients with diabetes. We describe the advantages and disadvantages and the rationale for their use. RECENT FINDINGS We compared commercially available insulin dosing software, namely, Glucommander™, EndoTool®, GlucoStabilizer®, and GlucoTab®, in addition to computerized order entry systems that are available in electronic health records. The common feature among these eGMS is their ability to limit occurrences of hypoglycemia while achieving and maintaining patients at target blood glucose level. More research needs to be done examining the efficacy of eGMS in disease-specific states and their benefits and utility in preventing adverse outcomes. Their long-term benefits to health care systems are beginning to emerge in cost-saving benefits and prevention of readmissions.
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Affiliation(s)
- Jagdeesh Ullal
- Center for Diabetes and Endocrinology, Division of Endocrinology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Joseph A Aloi
- Department of Internal Medicine, Section on Endocrinology and Metabolism, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Horton WB, Law S, Darji M, Conaway MR, Akbashev MY, Kubiak NT, Kirby JL, Thigpen SC. A MULTICENTER STUDY EVALUATING PERCEPTIONS AND KNOWLEDGE OF INPATIENT GLYCEMIC CONTROL AMONG RESIDENT PHYSICIANS: ANALYZING THEMES TO INFORM AND IMPROVE CARE. Endocr Pract 2019; 25:1295-1303. [PMID: 31412227 DOI: 10.4158/ep-2019-0299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: In this descriptive study, we evaluated perceptions and knowledge of inpatient glycemic control among resident physicians. Methods: We performed this study at four academic medical centers: the University of Mississippi Medical Center, University of Virginia Health System, University of Louisville Health Sciences Center, and Emory University. We designed a questionnaire, and Institutional Review Board approval was granted at each institution prior to study initiation. We then administered the questionnaire to Internal Medicine and Medicine-Pediatric resident physicians. Results: A total of 246 of 438 (56.2%) eligible resident physicians completed the Inpatient Glycemic Control Questionnaire (IGCQ). Most respondents (85.4%) reported feeling comfortable treating and managing inpatient hyperglycemia, and a majority (66.3%) agreed they had received adequate education. Despite self-reported comfort with knowledge, only 51.2% of respondents could identify appropriate glycemic targets in critically ill patients. Only 45.5% correctly identified appropriate inpatient random glycemic target values in noncritically ill patients, and only 34.1% of respondents knew appropriate preprandial glycemic targets in noncritically ill patients. A small majority (54.1%) were able to identify the correct fingerstick glucose value that defines hypoglycemia. System issues were the most commonly cited barrier to successful inpatient glycemic control. Conclusion: Most respondents reported feeling comfortable managing inpatient hyperglycemia but had difficulty identifying appropriate inpatient glycemic target values. Future interventions could utilize the IGCQ as a pre- and postassessment tool and focus on early resident education along with improving system environments to aid in successful inpatient glycemic control. Abbreviations: DM = diabetes mellitus; Emory = Emory University Healthcare; IGC = inpatient glycemic control; IGCQ = Inpatient Glycemic Control Questionnaire; IRB = Institutional Review Board; PGY = postgraduate year; UMMC = University of Mississippi Medical Center; UVA = University of Virginia Health System; UL = University of Louisville Health Sciences Center.
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Pichardo-Lowden AR, Haidet PM. Closing the Loop: Optimizing Diabetes Care in the Hospital by Addressing Dispersed Information in Electronic Health Records and Using Clinical Decision Support. J Diabetes Sci Technol 2019; 13:783-789. [PMID: 30526010 PMCID: PMC6610603 DOI: 10.1177/1932296818817005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Multiple factors hinder the management of diabetes in hospitals. Amid the demands of practice, health care providers must collect, collate, and analyze multiple data points to optimally interpret glucose control and manage insulin dosing. Such data points are commonly dispersed in different sections of electronic health records (EHR), and the system for data display and physician interaction with the EHR are often poorly conducive to seamless clinical decision making. In this perspective article, we examine challenges in the process of EHR data retrieval, interpretation and decision making, using glucose management as an exemplar. We propose a conceptual, systems-based design for closing the loop between data gathering, analysis and decision making in the management of inpatient diabetes. This concept capitalizes on attributes of the EHR that can enable automated recognition of cases and provision of clinical recommendations.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Division of
Endocrinology, Diabetes and Metabolism, Penn State University, Milton S. Hershey
Medical Center, Hershey, PA, USA
- Penn State University College of
Medicine, Hershey, PA, USA
| | - Paul M. Haidet
- Penn State University College of
Medicine, Hershey, PA, USA
- Departments of Medicine, Humanities, and
Public Health Sciences and the Woodward Center for Excellence in Health Sciences
Education, Hershey, PA, USA
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Horton WB, Law S, Darji M, Conaway MR, Kubiak NT, Kirby JL, Thigpen SC. Construction and preliminary evaluation of the inpatient glycemic control questionnaire (IGCQ): a survey tool assessing perceptions and knowledge of resident physicians. BMC MEDICAL EDUCATION 2019; 19:228. [PMID: 31234836 PMCID: PMC6591905 DOI: 10.1186/s12909-019-1657-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 06/06/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Uncontrolled hyperglycemia in hospitalized patients, with or without diabetes mellitus, is associated with many adverse outcomes. Resident physicians are the primary managers of inpatient glycemic control (IGC) in many academic and community medical centers; however, no validated survey tools related to their perceptions and knowledge of IGC are currently available. As identification of common barriers to successful IGC amongst resident physicians may help foster better educational interventions (ultimately leading to improvements in IGC and patient care), we sought to construct and preliminarily evaluate such a survey tool. METHODS We developed the IGC questionnaire (IGCQ) by using previously published but unvalidated survey tools related to physician perspectives on inpatient glycemic control as a framework. We administered the IGCQ to a cohort of resident physicians from the University of Mississippi Medical Center, University of Louisville, Emory University, and the University of Virginia. We then used classical test theory and Rasch Partial Credit Model analyses to preliminarily evaluate and revise the IGCQ. The final survey tool contains 16 total items and three answer-choice categories for most items. RESULTS Two hundred forty-six of 438 (56.2%) eligible resident physicians completed the IGCQ during various phases of development. CONCLUSIONS We constructed and preliminarily evaluated the IGCQ, a survey tool that may be useful for future research into resident physician perceptions and knowledge of IGC. Future studies could seek to externally validate the IGCQ and then utilize the survey tool in pre- and post-intervention assessments.
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Affiliation(s)
- William B. Horton
- Divsion of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA USA
| | - Sidney Law
- Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Monika Darji
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Chicago, Chicago, IL USA
| | - Mark R. Conaway
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA USA
| | - Nancy T. Kubiak
- Division of General Internal Medicine, Palliative Medicine, and Medical Education, Department of Medicine, University of Louisville, Louisville, KY USA
| | - Jennifer L. Kirby
- Divsion of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA USA
| | - S. Calvin Thigpen
- Division of General Internal Medicine and Hypertension, Department of Medicine, University of Mississippi Medical Center, Jackson, MS USA
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41
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Tatalovic M, Lehmann R, Cheetham M, Nowak A, Battegay E, Rampini SK. Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review. BMJ Open 2019; 9:e028914. [PMID: 31154314 PMCID: PMC6549610 DOI: 10.1136/bmjopen-2019-028914] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES What is the most effective pharmacological intervention for glycaemic control in known type 2 diabetes mellitus (DM) without prior insulin treatment and newly started on systemic glucocorticoid therapy? DESIGN We conducted a systematic literature review. DATA SOURCES We searched MEDLINE, Embase and Cochrane Library databases and Google for articles from 2002 to July 2018. ELIGIBILITY CRITERIA We combined search terms relating to DM (patients, >16 years of age), systemic glucocorticoids, glycaemic control, randomised controlled trials (RCTs) and observational studies. DATA EXTRACTION AND SYNTHESIS We screened and evaluated articles, extracted data and assessed risk of bias and quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation guidelines. RESULTS Eight of 2365 articles met full eligibility criteria. Basal-bolus insulin (BBI) strategy for patients under systemic glucocorticoid therapy was comparatively effective but provided insufficient glucose control, depending on time of day. BBI strategy with long-acting insulin and neutral protamin Hagedorn as basal insulin provided similar overall glycaemic control. Addition of various insulin strategies to standard BBI delivered mixed results. Intermediate-acting insulin (IMI) as additional insulin conferred no clear benefits, and glycaemic control with sliding scale insulin was inferior to BBI or IMI. No studies addressed whether anticipatory or compensatory insulin adjustments are better for glycaemic control. CONCLUSION The lack of suitably designed RCTs and observational studies, heterogeneity of interventions, target glucose levels and glucose monitoring, poor control of DM subgroups and low to moderate quality of evidence render identification of optimal pharmacological interventions for glycaemic control and insulin management difficult. Even findings on the widely recommended BBI regimen as intensive insulin therapy for patients with DM on glucocorticoids are inconclusive. High-quality evidence from studies with well-defined DM phenotypes, settings and treatment approaches is needed to determine optimal pharmacological intervention for glycaemic control. PROSPERO REGISTRATION NUMBER CRD42015024739.
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Affiliation(s)
- Milos Tatalovic
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Roger Lehmann
- Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Marcus Cheetham
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
- Center of Competence Multimorbidity, University of Zurich, Zurich, Switzerland
| | - Albina Nowak
- Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Edouard Battegay
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
- Center of Competence Multimorbidity, University of Zurich, Zurich, Switzerland
| | - Silvana K Rampini
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
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42
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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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43
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Kyi M, Colman PG, Wraight PR, Reid J, Gorelik A, Galligan A, Kumar S, Rowan LM, Marley KA, Nankervis AJ, Russell DM, Fourlanos S. Early Intervention for Diabetes in Medical and Surgical Inpatients Decreases Hyperglycemia and Hospital-Acquired Infections: A Cluster Randomized Trial. Diabetes Care 2019; 42:832-840. [PMID: 30923164 DOI: 10.2337/dc18-2342] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/01/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate if early electronic identification and bedside management of inpatients with diabetes improves glycemic control in noncritical care. RESEARCH DESIGN AND METHODS We investigated a proactive or early intervention model of care (whereby an inpatient diabetes team electronically identified individuals with diabetes and aimed to provide bedside management within 24 h of admission) compared with usual care (a referral-based consultation service). We conducted a cluster randomized trial on eight wards, consisting of a 10-week baseline period (all clusters received usual care) followed by a 12-week active period (clusters randomized to early intervention or usual care). Outcomes were adverse glycemic days (AGDs) (patient-days with glucose <4 or >15 mmol/L [<72 or >270 mg/dL]) and adverse patient outcomes. RESULTS We included 1,002 consecutive adult inpatients with diabetes or new hyperglycemia. More patients received specialist diabetes management (92% vs. 15%, P < 0.001) and new insulin treatment (57% vs. 34%, P = 0.001) with early intervention. At the cluster level, incidence of AGDs decreased by 24% from 243 to 186 per 1,000 patient-days in the intervention arm (P < 0.001), with no change in the control arm. At the individual level, adjusted number of AGDs per person decreased from a mean 1.4 (SD 1.6) to 1.0 (0.9) days (-28% change [95% CI -45 to -11], P = 0.001) in the intervention arm but did not change in the control arm (1.8 [2.0] to 1.5 [1.8], -9% change [-25 to 6], P = 0.23). Early intervention reduced overt hyperglycemia (55% decrease in patient-days with mean glucose >15 mmol/L, P < 0.001) and hospital-acquired infections (odds ratio 0.20 [95% CI 0.07-0.58], P = 0.003). CONCLUSIONS Early identification and management of inpatients with diabetes decreased hyperglycemia and hospital-acquired infections.
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Affiliation(s)
- Mervyn Kyi
- Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter G Colman
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Paul R Wraight
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jane Reid
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Alexandra Gorelik
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Australian Catholic University, Fitzroy, Victoria, Australia
| | - Anna Galligan
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Shanal Kumar
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lois M Rowan
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Katie A Marley
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | | | | | - Spiros Fourlanos
- Royal Melbourne Hospital, Parkville, Victoria, Australia .,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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44
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Hellman R. An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes. Endocr Pract 2019; 20:1097-9. [PMID: 25100399 DOI: 10.4158/ep14283.co] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Richard Hellman
- Heart of America Diabetes Research Foundation, 2790 Clay Edwards Drive Suite 1250, North Kansas City, MO 64116
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45
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Crisher MA, Giuliano CA, Hartner CL. Insulin Detemir Versus Insulin Glargine in the Hospital: Do Hypoglycemia Rates Differ? Clin Diabetes 2019; 37:167-171. [PMID: 31057223 PMCID: PMC6468821 DOI: 10.2337/cd18-0065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
IN BRIEF Several studies have compared the safety and efficacy of insulin detemir and insulin glargine; however, most have been conducted in the ambulatory care setting. This retrospective cohort study compared hypoglycemia rates between the two basal insulin analogs in hospitalized patients with diabetes. No difference was found between the two insulin cohorts in the proportion of patients who experienced hypoglycemic events.
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Affiliation(s)
| | - Christopher A. Giuliano
- Ascension St. John Hospital, Detroit, MI
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, MI
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46
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Abstract
It is the position of American Association of Diabetes Educators (AADE) that all inpatient interdisciplinary teams include a diabetes educator to lead or support improvement efforts that affect patients hospitalized with diabetes or hyperglycemia. This not only encompasses patient and family education but education of interdisciplinary team members and achievement of diabetes-related organizational quality metrics and performance outcomes.
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47
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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48
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Momesso DP, Costa Filho RC, Costa JLF, Saddy F, Mesquita A, Calomeni M, Silva CDS, Farret J, Vasques ML, Santos AG, Cabral APV, Ribeiro D, Reis L, Muino MDFM, Vitorino RS, Monteiro CA, Tinoco E, Volschan A. Impact of an inpatient multidisciplinary glucose control management program. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:514-522. [PMID: 30462804 PMCID: PMC10118654 DOI: 10.20945/2359-3997000000071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 06/13/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Glycemic control has been increasingly recognized as a critical element in inpatient care, but optimal management of blood glucose in the hospital setting remains challenging. The aims of this study were to describe and evaluate the impact of the implementation of an inpatient multidisciplinary glucose control management program on glucose control in hospitalized patients. MATERIALS AND METHODS Retrospective analysis of medical records and glucose monitoring data obtained by point- of-care testing (POCT) in hospitalized patients before (May 2014) and after (June 2015 and May 2017) the implementation of the program. RESULTS We analyzed 6888, 7290, and 7669 POCTs from 389, 545, and 475 patients in May 2014, June 2015, and May 2017, respectively. Hyperglycemia (≥ 180 mg/ dL) occurred in 23.5%, 19.6%, and 19.3% POCTs in May 2014, June 2015, and May/2017, respectively (p < 0.001), while severe hyperglycemia (≥ 300 mg/dL) was observed in 2.5%, 2.2%, and 1.8% of them, respectively (p = 0.003). Hyperglycemia (≥ 180 mg/dL) reduced significantly from May 2014 to June 2015 (16.3%, p < 0.001) and from May 2014 to May 2017 (178%, p < 0.001). No significant changes occurred in hypoglycemic parameters. CONCLUSIONS The implementation of an inpatient multidisciplinary glucose control management program led to significant reductions in hyperglycemic events. The key elements for this achievement were the development of institutional inpatient glycemic control protocols, establishment of a multidisciplinary team, and continuing educational programs for hospital personnel. Altogether, these actions resulted in improvements in care processes, patient safety, and clinical outcomes of hospitalized patients.
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Affiliation(s)
| | | | | | - Felipe Saddy
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ, Brasil
| | | | | | | | | | | | | | | | | | - Luciana Reis
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ, Brasil
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49
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Gianchandani RY, Pasquel FJ, Rubin DJ, Dungan KM, Vellanki P, Wang H, Anzola I, Gomez P, Hodish I, Lathkar-Pradhan S, Iyengar J, Umpierrez GE. THE EFFICACY AND SAFETY OF CO-ADMINISTRATION OF SITAGLIPTIN WITH METFORMIN IN PATIENTS WITH TYPE 2 DIABETES AT HOSPITAL DISCHARGE. Endocr Pract 2018; 24:556-564. [PMID: 29949432 DOI: 10.4158/ep-2018-0036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Few randomized controlled trials have focused on the optimal management of patients with type 2 diabetes (T2D) during the transition from the inpatient to outpatient setting. This multicenter open-label study explored a discharge strategy based on admission hemoglobin A1c (HbA1c) to guide therapy in general medicine and surgery patients with T2D. METHODS Patients with HbA1c ≤7% (53 mmol/mol) were discharged on sitagliptin and metformin; patients with HbA1c between 7 and 9% (53-75 mmol/mol) and those >9% (75 mmol/mol) were discharged on sitagliptinmetformin with glargine U-100 at 50% or 80% of the hospital daily dose. The primary outcome was change in HbA1c at 3 and 6 months after discharge. RESULTS Mean HbA1c on admission for the entire cohort (N = 253) was 8.70 ± 2.3% and decreased to 7.30 ± 1.5% and 7.30 ± 1.7% at 3 and 6 months ( P<.001). Patients with HbA1c <7% went from 6.3 ± 0.5% to 6.3 ± 0.80% and 6.2 ± 1.0% at 3 and 6 months. Patients with HbA1c between 7 and 9% had a reduction from 8.0 ± 0.6% to 7.3 ± 1.1% and 7.3 ± 1.3%, and those with HbA1c >9% from 11.3 ± 1.7% to 8.0 ± 1.8% and 8.0 ± 2.0% at 3 and 6 months after discharge (both P<.001). Clinically significant hypoglycemia (<54 mg/dL) was observed in 4%, 4%, and 7% among patients with a HbA1c <7%, 7 to 9%, and >9%, while a glucose <40 mg/dL was reported in <1% in all groups. CONCLUSION The proposed HbA1c-based hospital discharge algorithm using a combination of sitagliptin-metformin was safe and significantly improved glycemic control after hospital discharge in general medicine and surgery patients with T2D. ABBREVIATIONS BG = blood glucose; DPP-4 = dipeptidyl peptidase-4; eGFR = estimated glomerular filtration rate; HbA1c = hemoglobin A1c; T2D = type 2 diabetes.
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50
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Bally L, Thabit H, Hartnell S, Andereggen E, Ruan Y, Wilinska ME, Evans ML, Wertli MM, Coll AP, Stettler C, Hovorka R. Closed-Loop Insulin Delivery for Glycemic Control in Noncritical Care. N Engl J Med 2018; 379:547-556. [PMID: 29940126 DOI: 10.1056/nejmoa1805233] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In patients with diabetes, hospitalization can complicate the achievement of recommended glycemic targets. There is increasing evidence that a closed-loop delivery system (artificial pancreas) can improve glucose control in patients with type 1 diabetes. We wanted to investigate whether a closed-loop system could also improve glycemic control in patients with type 2 diabetes who were receiving noncritical care. METHODS In this randomized, open-label trial conducted on general wards in two tertiary hospitals located in the United Kingdom and Switzerland, we assigned 136 adults with type 2 diabetes who required subcutaneous insulin therapy to receive either closed-loop insulin delivery (70 patients) or conventional subcutaneous insulin therapy, according to local clinical practice (66 patients). The primary end point was the percentage of time that the sensor glucose measurement was within the target range of 100 to 180 mg per deciliter (5.6 to 10.0 mmol per liter) for up to 15 days or until hospital discharge. RESULTS The mean (±SD) percentage of time that the sensor glucose measurement was in the target range was 65.8±16.8% in the closed-loop group and 41.5±16.9% in the control group, a difference of 24.3±2.9 percentage points (95% confidence interval [CI], 18.6 to 30.0; P<0.001); values above the target range were found in 23.6±16.6% and 49.5±22.8% of the patients, respectively, a difference of 25.9±3.4 percentage points (95% CI, 19.2 to 32.7; P<0.001). The mean glucose level was 154 mg per deciliter (8.5 mmol per liter) in the closed-loop group and 188 mg per deciliter (10.4 mmol per liter) in the control group (P<0.001). There was no significant between-group difference in the duration of hypoglycemia (as defined by a sensor glucose measurement of <54 mg per deciliter; P=0.80) or in the amount of insulin that was delivered (median dose, 44.4 U and 40.2 U, respectively; P=0.50). No episode of severe hypoglycemia or clinically significant hyperglycemia with ketonemia occurred in either trial group. CONCLUSIONS Among inpatients with type 2 diabetes receiving noncritical care, the use of an automated, closed-loop insulin-delivery system resulted in significantly better glycemic control than conventional subcutaneous insulin therapy, without a higher risk of hypoglycemia. (Funded by Diabetes UK and others; ClinicalTrials.gov number, NCT01774565 .).
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Affiliation(s)
- Lia Bally
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Hood Thabit
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Sara Hartnell
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Eveline Andereggen
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Yue Ruan
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Malgorzata E Wilinska
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Mark L Evans
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Maria M Wertli
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Anthony P Coll
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Christoph Stettler
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
| | - Roman Hovorka
- From the Departments of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism (L.B., E.A., C.S.) and General Internal Medicine (L.B., M.M.W.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and the Wellcome Trust-MRC Institute of Metabolic Science (L.B., H.T., Y.R., M.E.W., M.L.E., A.P.C., R.H.) and the Department of Pediatrics (M.E.W., R.H.), University of Cambridge, and the Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust (S.H., M.L.E., A.P.C.), Cambridge, and the Manchester University Hospitals NHS Foundation, Manchester Academic Health Science Centre (H.T.), and the Division of Diabetes, Endocrinology, and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester (H.T.), Manchester - all in the United Kingdom
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