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Priyadi A, Permana H, Muhtadi A, Sumiwi SA, Sinuraya RK, Suwantika AA. Cost-Effectiveness Analysis of Type 2 Diabetes Mellitus (T2DM) Treatment in Patients with Complications of Kidney and Peripheral Vascular Diseases in Indonesia. Healthcare (Basel) 2021; 9:healthcare9020211. [PMID: 33669379 PMCID: PMC7920312 DOI: 10.3390/healthcare9020211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/25/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a chronic disease with high-cost treatment. This study aimed to analyze the cost-effectiveness of T2DM treatment in hospitalized patients with complications of kidney and peripheral vascular disease (PVD) in Indonesia by focusing on patients of Health Social Security Agency (BPJS Kesehatan). An observational study was applied by collecting data retrospectively from patients’ medical record at the biggest public hospital in West Java Province, Indonesia. Two perspectives of payer and healthcare provider were applied to estimate the treatment cost. We considered following inclusion criteria: (i) Hospitalized T2DM patients without complication, with complications of kidney and PVD during 2014–2017; (ii) member of BPJS Kesehatan; (iii) >18 years old patients; and (iv) patients with complete medical record data. The results showed that the majority patients were female (56.72%), 45–64 years old (69.40%), and had a length of stay at 4–10 days (54.48%). The greatest contributions in the total treatment cost were found to be hospital room, medical services and medicines for the treatment of T2DM without complications, with complications of kidney and PVD, respectively. From the perspective of payer, the incremental cost-effectiveness ratios (ICERs) of T2DM treatment with complications of kidney and PVD would be IDR 215,723 and IDR 234,591 per 1 mg/dL blood glucose reduction, respectively. From the perspective of healthcare provider, the ICERs of T2DM treatment with complications of kidney and PVD would be IDR 166,289 and IDR 681,853 per 1 mg/dL blood glucose reduction in both perspectives (1 US$ = IDR 13,451). In a comparison with T2DM without complication, reducing 1 mg/dL blood glucose in T2DM treatment with complication of PVD would require higher cost than in T2DM treatment with complication of kidney from both perspectives.
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Affiliation(s)
- Akhmad Priyadi
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung 40132, Indonesia; (A.P.); (A.M.); (S.A.S.); (R.K.S.)
- Faculty of Pharmacy, Universitas Bhakti Kencana, Bandung 40164, Indonesia
| | - Hikmat Permana
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung 40132, Indonesia;
| | - Ahmad Muhtadi
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung 40132, Indonesia; (A.P.); (A.M.); (S.A.S.); (R.K.S.)
| | - Sri A. Sumiwi
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung 40132, Indonesia; (A.P.); (A.M.); (S.A.S.); (R.K.S.)
| | - Rano K. Sinuraya
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung 40132, Indonesia; (A.P.); (A.M.); (S.A.S.); (R.K.S.)
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung 40132, Indonesia
| | - Auliya A. Suwantika
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung 40132, Indonesia; (A.P.); (A.M.); (S.A.S.); (R.K.S.)
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung 40132, Indonesia
- Center for Health Technology Assessment, Universitas Padjadjaran, Bandung 40132, Indonesia
- Correspondence: ; Tel.: +62-22-7796200
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Pichardo-Lowden A, Umpierrez G, Lehman EB, Bolton MD, DeFlitch CJ, Chinchilli VM, Haidet PM. Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes. BMJ Open Diabetes Res Care 2021; 9:9/1/e001557. [PMID: 33462075 PMCID: PMC7816906 DOI: 10.1136/bmjdrc-2020-001557] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Innovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations. RESEARCH DESIGN AND METHODS The tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9-4.4 mmol/L (70-80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods. RESULTS When active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, p<0.001). Hypoglycemia or impending hypoglycemia (1548 vs 1349, OR=1.15, p=0.050) were unrelated to the CDS tool on subsequent analysis. Inappropriate use of SSI monotherapy in type 1 diabetes (10 vs 22, OR=0.36, p=0.073), inappropriate use of SSI monotherapy in type 2 diabetes (2519 vs 2748, OR=0.97, p=0.632), and in stress hyperglycemia subjects (1617 vs 1488, OR=1.30, p<0.001) were recognized. CONCLUSION EMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.
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Affiliation(s)
- Ariana Pichardo-Lowden
- Department of Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Matthew D Bolton
- Department of Information Services, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christopher J DeFlitch
- Department of Emergency Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Paul M Haidet
- Department of Medicine, Public Health Sciences, and Humanities, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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El Khoury G, Mansour H, Kabbara WK, Chamoun N, Atallah N, Salameh P. Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon. Curr Diabetes Rev 2019; 15:133-140. [PMID: 29357807 DOI: 10.2174/1573399814666180119142254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions. OBJECTIVE The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients. METHODS The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence. RESULTS A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%). CONCLUSION Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.
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Affiliation(s)
- Ghada El Khoury
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Hanine Mansour
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Wissam K Kabbara
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Nibal Chamoun
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Nadim Atallah
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Pascale Salameh
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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Colón-Ramos U, Rodríguez-Ayuso I, Gebrekristos HT, Roess A, Pérez CM, Simonsen L. Transnational Mortality Comparisons Between Archipelago and Mainland Puerto Ricans. J Immigr Minor Health 2018; 19:1009-1017. [PMID: 27334006 DOI: 10.1007/s10903-016-0448-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Puerto Ricans in the US experience higher deaths from diabetes and other causes compared to non-Hispanic Whites and other Hispanic groups. We compared mortality in Puerto Rico to that of Puerto Ricans in the US as a first step to investigate if similar or worse mortality patterns originate from the sending country (Puerto Rico). Age-adjusted death rates were generated using national vital statistics databases in the US and territories for all-cause and the top ten causes of death among Hispanics in 2009. Mortality ratios in the archipelago of Puerto Rico (APR) were compared to mainland US Puerto Ricans (MPR). Rates for other ethnic/racial groups (Mexican Americans, Cubans, and non-Hispanic Whites, Blacks, American Indians, and Asians) were calculated to provide a context. APR had significantly higher all-cause mortality and death rates for diabetes, nephritis, pneumonia/influenza, and homicide/assault compared to MPR (APR/MPR ratio for all-cause: 1.08, diabetes: 2.04, nephritis: 1.84, pneumonia/influenza: 1.33, homicide/assault: 3.15). Death rates for diabetes and homicide/assault (particularly among men) were higher among APR compared to any other racial/ethnic groups in the US. In contrast, deaths from heart disease, cancer, and chronic liver disease were significantly lower for APR compared to MPR (MPR/APR ratio 0.72, 0.91, 0.41, respectively). Among APR women, death rates for these causes were also lower compared to any other group in the US. Substantial mortality variability exists between Puerto Ricans in Puerto Rico and those in the US, re-emphasizing the need to study of how socio-environmental determinants of health differ in sending and receiving countries. Explanations for disparate rates include access to and availability of healthcare and unique factors related to the migration experience of this group.
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Affiliation(s)
- Uriyoán Colón-Ramos
- Department of Global Health, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Avenue, Washington, DC, 20037, USA.
| | | | - Hirut T Gebrekristos
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Amira Roess
- Department of Global Health, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Avenue, Washington, DC, 20037, USA
| | - Cynthia M Pérez
- Department of Biostatistics and Epidemiology, Graduate School of Public Health, University of Puerto Rico, Medical Sciences Campus, San Juan, PR, USA
| | - Lone Simonsen
- Department of Global Health, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Avenue, Washington, DC, 20037, USA
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Abstract
Diabetes and hyperglycemia are present in over one-third of inpatients in internal medicine units and are associated with worse prognosis in multiple morbidities. Treatment of inpatient hyperglycemia is usually with basal bolus insulin in a dose calculated by the patient's weight, with lower doses recommended in patients who are at a higher risk for hypoglycemia. Other antihyperglycemic medications and insulin regimens can be used in selected patients. There are no adequately powered studies on the effect of improving glycemic control on hospitalization outcomes in non-critically ill patients in internal medicine units, and in most patients a modest glucose target of 140-180 mg/dL is recommended. A structured discharge plan should intensify antihyperglycemic treatment as needed and include an outpatient follow-up appointment shortly after discharge.
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Affiliation(s)
- Irit Hochberg
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
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Hao S, Zhang N, Fish AF, Yuan X, Liu L, Li F, Fang Z, Lou Q. Inpatient glycemic management in internal medicine: an observational multicenter study in Nanjing, China. Curr Med Res Opin 2017; 33:1371-1377. [PMID: 28504012 DOI: 10.1080/03007995.2017.1330256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIMS To evaluate the prevalence of hyperglycemia among inpatients in internal medicine, and specifically, to assess the glycemic management of inpatients in non-endocrinology departments in three large urban hospitals in China. METHODS A multicenter observational study was conducted using electronic health records, and a survey of 1939 patients who were admitted to internal medicine units and followed until discharge. Those with previously diagnosed diabetes, newly diagnosed diabetes, or impaired fasting glucose were included. Aspects of glycemic management examined were (a) hyperglycemia, (b) endocrinology consultation for hyperglycemia and (c) hypoglycemia. RESULTS The prevalence of hyperglycemia in internal medicine was 45.7% (886 out of 1939). A total of 741 (83.6%) patients were treated by non-endocrinology departments; of those, 230 (31.1%) were in poor glycemic control and needed an endocrinology consultation. Yet only 57 (24.8%) received one. In 4 cases, the physician did not follow the consultants' advice. Among the remaining 53 consulted patients, 35 (66.1%) were still in poor glycemic control, yet only about half received a second consultation. Finally, among patients treated in non-endocrinology departments, 58 (7.8%) had hypoglycemia; less than half retested their blood glucose after treatment. CONCLUSIONS The majority of patients with hyperglycemia were in non-endocrinology departments. Their glycemic management was poor; the endocrinology consultation rate was low and the result was suboptimal. Also, the management of hypoglycemia was not ideal. Therefore, improving glycemic management is urgently needed in Chinese hospitals.
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Affiliation(s)
- Shujie Hao
- a Department of Health Education , Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine , Nanjing , Jiangsu Province , China
- b Nursing College, Nanjing University of Chinese Medicine , Nanjing , Jiangsu Province , China
| | - Ning Zhang
- c Department of Endocrinology , Nanjing Drum Tower Hospital , Nanjing , Jiangsu Province , China
| | - Anne Folta Fish
- d College of Nursing , University of Missouri-St. Louis , St. Louis , MO , USA
| | - Xiaodan Yuan
- a Department of Health Education , Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine , Nanjing , Jiangsu Province , China
| | - Lin Liu
- a Department of Health Education , Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine , Nanjing , Jiangsu Province , China
| | - Fan Li
- a Department of Health Education , Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine , Nanjing , Jiangsu Province , China
| | - Zhaohui Fang
- e Department of Endocrinology , The First Affiliated Hospital of Anhui University of Chinese Medicine , Hefei , China
| | - Qingqing Lou
- a Department of Health Education , Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine , Nanjing , Jiangsu Province , China
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