Diabetes care in hospitalized noncritically ill patients: More evidence for clinical inertia and negative therapeutic momentum

Cook, Curtiss B.; Castro, Janna C.; Schmidt, Ronald; Gauthier, Susanne M.; Whitaker, Michael; Roust, Lori R.; Argueta, Rodolfo; Hull, Bryan P.; Zimmerman, Richard S.

doi:10.1002/jhm.188

Cited by 126 publications

(105 citation statements)

References 23 publications

(34 reference statements)

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“…19 Additionally, we included only those cases that did not have an endocrinology consultation. The relationship of changes in inpatient therapy with respect to hyperglycemia was assessed in two ways.…”

Section: Discussionmentioning

confidence: 99%

“…Patients discharged with an ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnosis code for diabetes (ICD-9-CM code 250.xx) were identified in a search of the hospital's electronic billing records as described previously. 19 Adult patients (≥18 years old) with a diagnosis of diabetes who were undergoing a surgical procedure between January 1 and April 30, 2011, were identified from discharge data. The institutional review board approved this study.…”

Section: Case Selectionmentioning

confidence: 99%

“…Results were then stratified into >180, >200, >250, >300, or >350 mg/dl and into <40, <50, <60, or <70 mg/dl, respectively, as previously described. 19 …”

Section: Assessment Of Glucose Controlmentioning

confidence: 99%

“…If a patient was receiving premixed insulin, it was placed in the basal plus short-acting category. 19 …”

Section: Definitions Of Inpatient Hyperglycemia Treatmentmentioning

confidence: 99%

“…17 We first described clinical inertia in the hospital with regards to insulin administration in 2006, 18 with further evidence found subsequently. 19 Others have also observed clinical inertia in the treatment of inpatient diabetes. [20][21][22] Although clinical inertia has been shown to occur in the management of a general population of hospitalized patients with diabetes, this has not been studied specifically in surgical patients with diabetes.…”

Section: Introductionmentioning

confidence: 99%

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Clinical Inertia during Postoperative Management of Diabetes Mellitus: Relationship between Hyperglycemia and Insulin Therapy Intensification

Coan

Schlinkert

Beck

et al. 2013

J Diabetes Sci Technol

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Objective:Our objective was to assess the application of insulin regimens in surgical postoperative patients with diabetes. Methods:A chart review was conducted of patients with diabetes who were hospitalized postoperatively between January 1 and April 30, 2011. Analysis was restricted to patients hospitalized for ≥3 days and excluded cases with an endocrinology consult. Insulin regimens were categorized as "basal plus short acting," "short acting only," or "none," and the pattern of use was evaluated by hyperglycemia severity according to tertiles of both mean glucose and the number of glucose measurements >180 mg/dl. Results:Among cases selected for analysis (n = 119), examination of changes in insulin use based on tertiles of mean glucose showed that use of basal plus short-acting insulin increased from 10% in the lowest tertile (mean glucose, 120 mg/dl) to 18% in the highest tertile (mean glucose, 198 mg/dl; p < .01); however, 70% of patients in the highest tertile continued to receive short-acting insulin only, with 12% receiving no insulin. Intensification of insulin to a basal plus short-acting regimen was also seen when changes were evaluated by the number of measurements >180 mg/dl (p < .01), but 70% and 12% of patients in the highest tertile still remained only on short-acting insulin or received no insulin, respectively. Conclusions:Use of basal plus short-acting insulin therapy increased with worsening hyperglycemia, but many cases did not have therapy intensified to the recommended insulin regimen-evidence of clinical inertia. Strategies should be devised to overcome inpatient clinical inertia in the treatment of postoperative patients with diabetes.

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Section: Discussionmentioning

confidence: 99%

Section: Case Selectionmentioning

confidence: 99%

“…Results were then stratified into >180, >200, >250, >300, or >350 mg/dl and into <40, <50, <60, or <70 mg/dl, respectively, as previously described. 19 …”

Section: Assessment Of Glucose Controlmentioning

confidence: 99%

“…If a patient was receiving premixed insulin, it was placed in the basal plus short-acting category. 19 …”

Section: Definitions Of Inpatient Hyperglycemia Treatmentmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Clinical Inertia during Postoperative Management of Diabetes Mellitus: Relationship between Hyperglycemia and Insulin Therapy Intensification

Coan

Schlinkert

Beck

et al. 2013

J Diabetes Sci Technol

Self Cite

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Development and Validation of a Machine Learning Model to Predict Near-Term Risk of Iatrogenic Hypoglycemia in Hospitalized Patients

et al. 2021

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Paradoxical Association of Hyperglycemia and Surgical Complications Among Patients With and Without Diabetes

et al. 2022

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IMPORTANCE Surgical complications associated with perioperative hyperglycemia are conventionally associated with diabetes, but, paradoxically, prior cohort studies have found that patients without diabetes have greater risk of complications at similar levels of hyperglycemia compared with patients with diabetes.OBJECTIVE To describe the association between perioperative hyperglycemia and surgical complications in a population of surgical patients without diabetes receiving routine blood glucose testing and insulin administration and to evaluate the potential correlation of perioperative hyperglycemia. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study of National Surgical Quality Improvement Program-defined complications after operation took place at a single academic medical center hospital from January 2013 to October 2016. Consecutive patients undergoing general, vascular, and gynecologic operations who were expected to have at least a 48-hour admission were included. Hyperglycemia was defined as blood glucose level of 140 mg/dL or higher within 24 hours after surgery. Multivariate regression was used to assess the association of hyperglycemia and complications, stratified by hyperglycemia severity and adjusted for diabetes status. Analysis began in February 2022.EXPOSURES Routine blood glucose testing and insulin administration. MAIN OUTCOMES AND MEASURESThe main outcomes are odds of experiencing perioperative hyperglycemia and postoperative complication, comparing patients with and without diabetes. RESULTSA total of 7634 patients (mean [SD] age, 53.5 [15.1] years; 6664 patients without diabetes [83.3%] and 970 patients with diabetes [17.7%]) underwent general (6204 [81.3%]), vascular (208 [2.7%]), and gynecologic (1222 [16%]) operations. Of these, 5868 (77%) had blood glucose testing (4899 individuals without diabetes [73.5%] and 969 [99.9%] with diabetes). Hyperglycemia occurred in 882 patients with diabetes (91%)and 2484 patients without diabetes (50.7%). Of those with blood glucose level more than 180 mg/dL, 1388 (72.7%) received insulin (658 patients with diabetes who had hyperglycemia [91%] and 680 patients without diabetes who had hyperglycemia [61%]). Adjusted odds of experiencing a complication were 83% greater for patients without vs with diabetes at blood glucose level of 140 to 179 mg/dL (odds ratio, 1.83 [95% CI, 0.93-3.6]), 49% greater for blood glucose level of 180 to 249 mg/dL (odds ratio, 1.49 [95% CI, 1.06-2.11]), and 88% greater for blood glucose level more than 250 mg/dL (odds ratio, 1.88 [95% CI, 1.11-3.17]). A similar trend was observed for serious complications. Insulin may mitigate the association of hyperglycemia and complications in patients without diabetes. CONCLUSIONS AND RELEVANCEIn this study, with near universal blood glucose testing and frequent insulin use, patients without diabetes paradoxically had worse outcomes than patients with diabetes at similar levels of hyperglycemia. Insulin may mitigate this effect and broader use may improve outcomes.

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Diabetes care in hospitalized noncritically ill patients: More evidence for clinical inertia and negative therapeutic momentum

Abstract: Editing, proofreading, and reference verification were provided by the Section of Scientific Publications, Mayo Clinic. BACKGROUND:Little is known about management of hyperglycemia in inpatients. OBJECTIVE: To gain insight into caring for hospitalized patients with hyperglyce-

Cited by 126 publications

References 23 publications

Clinical Inertia during Postoperative Management of Diabetes Mellitus: Relationship between Hyperglycemia and Insulin Therapy Intensification

Clinical Inertia during Postoperative Management of Diabetes Mellitus: Relationship between Hyperglycemia and Insulin Therapy Intensification

Development and Validation of a Machine Learning Model to Predict Near-Term Risk of Iatrogenic Hypoglycemia in Hospitalized Patients

Paradoxical Association of Hyperglycemia and Surgical Complications Among Patients With and Without Diabetes

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