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Philis-Tsimikas A, Diego ERNS, Vincent L, Lohnes S, Singleton C. Are we Ready for Real-Time Continuous Glucose Monitoring in the Hospital Setting? Benefits, Challenges, and Practical Approaches for Implementation : Case Vignette: Remote Real-Time Continuous Glucose Monitoring for Hospitalized Care in Quincy Koala. Curr Diab Rep 2024:10.1007/s11892-024-01549-z. [PMID: 39126617 DOI: 10.1007/s11892-024-01549-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE OF REVIEW While preliminary evidence for use of real-time continuous glucose monitoring (rtCGM) in the hospital setting is encouraging, challenges with currently available devices and technology will need to be overcome as part of real-world integration. This paper reviews the current evidence and guidelines regarding use of rtCGM in the hospital and suggests a practical approach to implementation. RECENT FINDINGS There is now a considerable body of real-world evidence on the benefits of reducing dysglycemia in the hospital using both traditional point-of-care (POC) glucose testing and rtCGM. Benefits of rtCGM include decreased frequency of hypo- and hyperglycemia with reduced need of frequent POC checks and it is both feasible and well-accepted by nursing staff and providers. If expansion to additional sites is to be considered, practical solutions will need to be offered. Recommendations for an operational workflow and tools are described to guide implementation in the non-ICU setting. Further testing in randomized controlled trials and real-world dissemination and implementation designs is needed, together with industry and technology collaborations, to further streamline the integration into health systems.
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Affiliation(s)
- Athena Philis-Tsimikas
- Scripps Whittier Diabetes Institute, 9834 Genesee Ave, Suite 300, La Jolla, CA, 92037, USA.
| | - Emily Rose N San Diego
- Scripps Whittier Diabetes Institute, 9834 Genesee Ave, Suite 300, La Jolla, CA, 92037, USA
- Scripps Research Translational Institute, La Jolla, CA, USA
| | - Lauren Vincent
- Scripps Whittier Diabetes Institute, 9834 Genesee Ave, Suite 300, La Jolla, CA, 92037, USA
- Scripps Health Inpatient Providers Medical Group, San Diego, CA, USA
| | - Suzanne Lohnes
- Scripps Whittier Diabetes Institute, 9834 Genesee Ave, Suite 300, La Jolla, CA, 92037, USA
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Choi WJ, Roberts S, Verma A, Razak F, O'Kane GM, Gallinger S, Hirschfield G, Hansen B, Sapisochin G. Characterizing the burden of biliary tract cancers across 28 hospitals in Ontario, Canada. Cancer 2024; 130:2294-2303. [PMID: 38361443 DOI: 10.1002/cncr.35249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND AIMS The incidence of biliary tract cancers (BTC) appears to be increasing worldwide. We analyzed the characteristics of BTC-related hospitalizations under medical services across 28 hospitals in Ontario, Canada. METHODS This study uses data collected by GEMINI, a hospital research data network. BTC-related hospitalizations from 2015 to 2021 under the Department of Medicine or intensive care unit were captured using the International Classification of Diseases, 10th revision, codes for intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma, and gallbladder cancers. RESULTS A total of 4596 BTC-related hospitalizations (2720 iCCA, 1269 extrahepatic cholangiocarcinoma, 607 gallbladder cancers) were analyzed. The number of unique patients with BTC-related hospitalizations increased over time. For iCCA-related hospitalizations, the total number of hospitalizations increased (from 385 in 2016 to 420 in 2021, p = .005), the hospital length of stay decreased over the study period (mean 10 days [SD, 12] in 2016 to 9 days [SD, 8] in 2021, p = .04), and the number of in-hospital deaths was stable (from 68 [18%] in 2016 to 55 [13%] in 2021, p = .62). Other outcomes such as 30-day readmissions, medical imaging tests, intensive care unit-specific hospitalizations, and length of stay were stable over time for all cohorts. The cost of hospitalization for the BTC cohort increased from median $8203 CAD (interquartile range, 5063-15,543) in 2017 to $8507 CAD (interquartile range, 5345-14,755) in 2021. CONCLUSIONS This real-world data analysis showed a rising number of patients with BTC-related hospitalizations and rising number of iCCA-related hospitalizations across 28 hospitals in Ontario between 2015 and 2021.
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Affiliation(s)
- Woo Jin Choi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Surain Roberts
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Amol Verma
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Fahad Razak
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Grainne M O'Kane
- Department of Medical Oncology, Trinity St. James's Cancer Institute, Trinity College Dublin, Dublin, Ireland
| | - Steven Gallinger
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Gideon Hirschfield
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina Hansen
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands
| | - Gonzalo Sapisochin
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
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Gao Y, Xu C, Yang A, Greco A, Horodezny S, Barnet C, Gucciardi E. How Outpatient Diabetes Education Programs Can Support Local Hospitals to Reduce Emergency Department Visits for Adults With Diabetes. Can J Diabetes 2022; 46:797-803. [PMID: 35931616 DOI: 10.1016/j.jcjd.2022.05.006] [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: 11/29/2021] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Our aim in this study was to assess the level of collaboration between a hospital-based outpatient diabetes education program (DEP) and emergency departments (EDs) for reducing number of ED revisits and hospital admissions by implementing intervention strategies to promote education services and streamlining referral and appointment intake processes. METHODS Patients (≥18 years of age) with an ED visit for hyper- or hypoglycemia were analyzed in 2 cohorts based on their intervention exposure. We conducted a single-cohort analysis of the exposed cohort (exposure to the intervention strategies) and compared 2-year outcomes with those of the unexposed cohort. Primary outcomes were hyper- or hypoglycemia-related ED revisit and hospitalization rates. Process outcomes included DEP referrals and DEP attendance. RESULTS There were no significant differences in ED revisits and hospital admissions between the exposed and unexposed cohorts. However, patients were more likely to be referred to a DEP by ED physicians (odds ratio [OR], 1.76; p=0.02) and to attend a DEP appointment (OR, 1.96; p<0.01) after intervention exposure. DEP attendees from both cohorts became less likely to revisit an ED (exposed: OR, 0.41; 95% confidence interval [CI], 0.23 to 0.71; unexposed: OR, 0.4; 95% CI, 0.15 to 1.15) at 12-month follow up; however, this reduction was sustained only among the exposed cohort (OR, 0.5; 95% CI, 0.31 to 0.81) and not the unexposed cohort (OR, 1.32; 95% CI, 0.60 to 2.91) at 24 months (p=0.04 when comparing the 2 cohorts). CONCLUSIONS Collaboration between outpatient DEPs with local EDs could effectively reduce diabetes-related ED revisits by increasing diabetes program utilization.
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Affiliation(s)
- Yueying Gao
- School of Nutrition, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Changchang Xu
- Division of Biostatistics, DLSPH, University of Toronto Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada; Modellicity, Inc, Toronto, Ontario, Canada
| | - Adalia Yang
- Clinical Public Health Division---Nutrition and Dietetics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Adrianna Greco
- School of Nutrition, Toronto Metropolitan University, Toronto, Ontario, Canada
| | | | - Cheryl Barnet
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Enza Gucciardi
- School of Nutrition, Toronto Metropolitan University, Toronto, Ontario, Canada.
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Powers B, Bucher A. An Economic Impact Model for Estimating the Value to Health Systems of a Digital Intervention for Diabetes Primary Care: Development and Usefulness Study. JMIR Form Res 2022; 6:e37745. [PMID: 36155985 PMCID: PMC9555334 DOI: 10.2196/37745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 08/26/2022] [Accepted: 09/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background Diabetes is associated with significant long-term costs for both patients and health systems. Regular primary care visits aligned with American Diabetes Association guidelines could help mitigate those costs while generating near-term revenue for health systems. Digital interventions prompting primary care visits among unengaged patients could provide significant economic value back to the health system as well as individual patients, but only few economic models have been put forth to understand this value. Objective Our objective is to establish a data-based method to estimate the economic impact to a health system of interventions promoting primary care visits for people with diabetes who have been historically unengaged with their care. The model was built with a focus on a specific digital health intervention, Precision Nudging, but can be used to quantify the value of other interventions driving primary care usage among patients with diabetes. Methods We developed an economic model to estimate the financial value of a primary care visit of a patient with diabetes to the health system. This model requires segmenting patients with diabetes according to their level of blood sugar control as measured by their most recent hemoglobin A1c value to understand how frequently they should be visiting a primary care provider. The model also accounts for the payer mix among the population with diabetes, documenting the percentage of insurance coverage through a commercial plan, Medicare, or Medicaid, as these influence the reimbursement rates for the services. Then, the model takes into consideration the population base rates of comorbid conditions for patients with diabetes and the associated current procedural terminology codes to understand what a provider can bill as well as the expected inpatient revenue from a subset of patients likely to require hospitalization based on the national hospitalization rates for people with diabetes. Physician reimbursement is subtracted from the total. Finally, the model also accounts for the level of patient engagement with the intervention to ensure a realistic estimate of the impact. Results We present a model to prospectively estimate the economic impact of a digital health intervention to encourage patients with documented diabetes diagnoses to attend primary care visits. The model leverages both publicly available and health system data to calculate the per appointment value (revenue) to the health system. The model offers a method to understand and test the financial impact of Precision Nudging or other primary care–focused diabetes interventions inclusive of costs driven by comorbid conditions. Conclusions The proposed economic model can help health systems understand and evaluate the estimated economic benefits of interventions focused on primary care and prevention for patients with diabetes as well as help intervention developers determine pricing for their product.
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Glycosuria Alters Uropathogenic Escherichia coli Global Gene Expression and Virulence. mSphere 2022; 7:e0000422. [PMID: 35477301 PMCID: PMC9241551 DOI: 10.1128/msphere.00004-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Uropathogenic Escherichia coli (UPEC) is the principal etiology of more than half of urinary tract infections (UTI) in humans with diabetes mellitus. Epidemiological data and studies in mouse model of ascending UTI have elucidated various host factors responsible for increasing the susceptibility of diabetic hosts to UPEC-UTI. In contrast, diabetic urinary microenvironment-mediated alterations in UPEC physiology and its contributions to shaping UPEC-UTI pathogenesis in diabetes have not been examined. To address our central hypothesis that glycosuria directly induces urinary virulence of UPEC, we compared virulence characteristics and gene expression in human UPEC strains UTI89 (cystitis) and CFT073 (pyelonephritis), exposed for 2 h in vitro to urine from either male or female donors that was either plain or supplemented with glucose to mimic glycosuria. Compared to control UPEC exposed to nutrient-rich culture medium, lysogeny broth, glycosuria-exposed UPEC exhibited significant increase in biofilm formation and reduction in the hemagglutination of Guinea pig erythrocytes (a measure of type 1 piliation). In addition, the analysis of UTI89 transcriptome by RNA sequencing revealed that 2-h-long, in vitro exposure to glycosuria also significantly alters expression of virulence and metabolic genes central to urinary virulence of UPEC. Addition of galactose as an alternative carbon source affected biofilm formation and gene expression profile of UPEC to an extent similar to that observed with glucose exposure. In summary, our results provide novel insights into how glycosuria-mediated rapid changes in UPEC fitness may facilitate UTI pathogenesis in the diabetic urinary microenvironment. IMPORTANCE Uropathogenic Escherichia coli (UPEC) is an important causative agent of urinary tract infections in diabetic humans. We examined the effects of in vitro exposure to glycosuria (presence of glucose in urine) on the virulence and gene expression by UPEC. Our results show that glycosuria rapidly (in 2 h) alters UPEC gene expression, induces biofilm formation, and suppresses type 1 piliation. These results offer novel insights into the pathogenesis of UPEC in the urinary tract.
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Rani S, Rahman SMF, Pricilla RA, David KV. Reasons for Hospitalisation among Patients with Diabetes in a Secondary Care Hospital in South India: A Retrospective Study. Indian J Endocrinol Metab 2022; 26:127-132. [PMID: 35873928 PMCID: PMC9302411 DOI: 10.4103/ijem.ijem_47_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/22/2022] [Accepted: 03/16/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus is a rapidly emerging non-communicable disease in India. It is associated with many life-long complications and higher rates of hospitalisations. The characteristics and reasons for hospitalisation among individuals with diabetes have not been documented in India. Such a study would direct policy makers in implementing prevention and education strategies and economic changes as needed. AIM AND OBJECTIVES The study aimed to study the characteristics and causes of admission of patients with diabetes admitted to a secondary care unit in South India. METHODS Aretrospective observation study of inpatient records of patients with diabetes aged 18 years and above admitted between January to December 2019 in a secondary care unit was done. The details of patient demographics, reason and outcome of admission were retrieved manually from paper-based patient records. Descriptive analysis was done using SPSS version 23. The study was approved by the Institutional Review Board of the institution. RESULTS Among the 479 admissions of patients with diabetes during 2019, the mean age of the admitted patients was 57.75 years. The majority of them had only one admission, 15% had re-admissions in the same time period. Approximately 78% of the admitted patients had one or more co-morbidities, 44.6% had hypertension as a co-morbidity. The principal cause of admission was infections (45%), followed by metabolic and endocrine causes (13.5%), cardiovascular disease (10.9%) and renal disease (7.96%). More than 80% of the admissions had a favourable outcome and were discharged. CONCLUSION This retrospective study demonstrated that the most common reason for admission among patients with diabetes to a secondary care unit in South India was infection. Many infections are preventable with effective treatment for diabetes and health education. Patients bear the costs of routine treatment for diabetes which is a fraction of the direct cost of hospitalisation and can drive them to huge economic losses. Therefore, interventions to promote standard treatment by primary and secondary care health professionals and self-awareness among patients need to be done to prevent hospitalisations.
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Affiliation(s)
- Santhosh Rani
- Department of Family Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sajitha MF Rahman
- Department of Family Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ruby A. Pricilla
- Department of Community Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kirubah V. David
- Department of Family Medicine, South Wakra Health Center, Primary Health Care Corporation, Qatar
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Paudel S, John PP, Poorbaghi SL, Randis TM, Kulkarni R. Systematic Review of Literature Examining Bacterial Urinary Tract Infections in Diabetes. J Diabetes Res 2022; 2022:3588297. [PMID: 35620571 PMCID: PMC9130015 DOI: 10.1155/2022/3588297] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/11/2022] [Indexed: 11/18/2022] Open
Abstract
This systematic review addresses the central research question, "what is known from the published, peer-reviewed literature about the impact of diabetes on the risk of bacterial urinary tract infections (UTI)?" We examine the results from laboratory studies where researchers have successfully adapted mouse models of diabetes to study the pathophysiology of ascending UTI. These studies have identified molecular and cellular effectors shaping immune defenses against infection of the diabetic urinary tract. In addition, we present evidence from clinical studies that in addition to diabetes, female gender, increased age, and diabetes-associated hyperglycemia, glycosuria, and immune impairment are important risk factors which further increase the risk of UTI in diabetic individuals. Clinical studies also show that the uropathogenic genera causing UTI are largely similar between diabetic and nondiabetic individuals, although diabetes significantly increases risk of UTI by drug-resistant uropathogenic bacteria.
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Affiliation(s)
- Santosh Paudel
- Department of Biology, University of Louisiana at Lafayette, Lafayette, LA, USA 70504
| | - Preeti P. John
- Department of Biology, University of Louisiana at Lafayette, Lafayette, LA, USA 70504
| | | | - Tara M. Randis
- Department of Pediatrics, University of South Florida, Tampa, FL, USA 33620
| | - Ritwij Kulkarni
- Department of Biology, University of Louisiana at Lafayette, Lafayette, LA, USA 70504
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