Perspectives on Learning and Clinical Practice Improvement for Diabetes in the Hospital: A Review of Educational Interventions for Providers

Pichardo-Lowden, Ariana; Haidet, Paul; Umpiérrez, Guillermo E.

doi:10.4158/ep161634.ra

Cited by 10 publications

(14 citation statements)

References 67 publications

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“…Recent calls have been made for IGC education to reach a larger population of learners and be adopted as a formal component of hospitals' quality planning, aiming to integrate clinical practice guidelines and optimize inpatient diabetes care (36). The Centers for Medicare and Medicaid Services recently contracted with Health Services Advisory Group to provide services for the Medication Measures Special Innovation Project, which is designed to develop measures that can be used to support quality healthcare delivery (37).…”

Section: Discussionmentioning

confidence: 99%

A Multicenter Study Evaluating Perceptions and Knowledge of Inpatient Glycemic Control Among Resident Physicians: Analyzing Themes to Inform and Improve Care

et al. 2019

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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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Section: Discussionmentioning

confidence: 99%

A Multicenter Study Evaluating Perceptions and Knowledge of Inpatient Glycemic Control Among Resident Physicians: Analyzing Themes to Inform and Improve Care

et al. 2019

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“…In a recent review of 16 educational programs in this area, 14 studies reported at least 1 clinical process or outcome measure, whereas 7 reported glycemic outcomes. 11 Among the 7 studies reporting glycemic outcomes, 3 showed reductions in rates of hyperglycemia with a concomitant increase in rates of hypoglycemia, 12,31,32 3 showed a reduction in rates of hyperglycemia with no change in rates of hypoglycemia, 13,33,34 and 1 study showed no effect on either hyperglycemia or hypoglycemia. 14 The educational formats in these studies included daily endocrine rounds with endocrine faculty, lectures/workshops, personal digital assistant (PDA), print algorithms, interactive discussions applying practice recommendations, games, case-based diabetes ward rounds, and refresher courses.…”

Section: Discussionmentioning

confidence: 99%

“…Educational formats that have been developed in this area include lectures, written guidelines or algorithms, clinical decision support tools, workshops, computer-based modules, online interactive tutorials, case-based ward rounds, refresher courses, and interactive assessments. 11 Most of these studies have demonstrated effectiveness in increasing provider knowledge of inpatient glucose management and improving process measures (eg, adherence to clinical practice guidelines regarding the use of basal-bolus insulin therapy) 4 ; on the other hand, results have been mixed regarding the effectiveness of educational interventions on glycemic outcomes. 11…”

Section: Introductionmentioning

confidence: 99%

“…11 Most of these studies have demonstrated effectiveness in increasing provider knowledge of inpatient glucose management and improving process measures (eg, adherence to clinical practice guidelines regarding the use of basal-bolus insulin therapy) 4 ; on the other hand, results have been mixed regarding the effectiveness of educational interventions on glycemic outcomes. 11…”

Section: Introductionmentioning

confidence: 99%

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Development, Implementation, and Evaluation of a Physician-Targeted Inpatient Glycemic Management Curriculum

Mathioudakis

Bashura

Boyer

et al. 2019

Journal of Medical Education and Curricular Development

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Objective: Diabetes is prevalent among hospitalized patients and there are multiple challenges to attaining glycemic control in the hospital setting. We sought to develop an inpatient glycemic management curriculum with stakeholder input and to evaluate the effectiveness of this educational program on glycemic control in hospitalized patients. Methods: Using the Six-Step Approach of Kern to Curriculum Development for Medical Education, we developed and implemented an educational curriculum for inpatient glycemic management targeted to internal medicine residents and hospitalists. We surveyed physicians (n = 73) and conducted focus group sessions (n = 18 physicians) to solicit input regarding educational deficits and desired format of the educational intervention. Based on feedback from the surveys and focus groups, we developed educational goals and objectives and a case-based curriculum, which was delivered over a 1-year period via in-person teaching sessions by 2 experienced diabetes physicians at 3 hospitals. Rates of hypoglycemia and hyperglycemia were evaluated among at-risk patient days using an interrupted time-series design. Results: We developed a mnemonic-based (SIGNAL) curriculum consisting of 10 modules, which covers key concepts of inpatient glycemic management and provides an approach to daily glycemic management: S = steroids, I = insulin, G = glucose, N = nutritional status, A = added dextrose, and L = labs. Following implementation of the curriculum, there was no difference in the rates of hyperglycemia in insulin-treated patients following the intervention; however, there was an increase in the rates of hypoglycemia defined as blood glucose (BG) ⩽ 70 mg/dL (5.6% vs 3.0%, P < .001) and clinically significant hypoglycemia defined as BG < 54 mg/dL (1.9% vs 0.8%, P = .01). There was poor penetration of the curriculum, with 60%, 20%, and 90% of the learning modules being delivered at the three participating hospitals, respectively. Conclusions: In this pilot study, a physician-targeted educational curriculum was not associated with improved glycemic control. Adapting the intervention to increase penetration and integrating the curriculum into existing clinical decision support tools may improve the effectiveness of the educational program on glycemic outcomes.

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“…The perspectives of inpatient providers ratified a need of clinicians, and endorsed the development of the CDS tool and its implementation program. 32 Prior to the integration of the tool in the clinical EMR environment, we conducted an exhaustive authentication process. This consisted in direct chart audits for accuracy verification of algorithmic workflows enabling cases detection.…”

Section: Methodsmentioning

confidence: 99%

Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes

Pichardo-Lowden

Umpiérrez

Lehman

et al. 2021

BMJ Open Diab Res Care

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IntroductionInnovative 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 methodsThe 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.ResultsWhen 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.ConclusionEMR 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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Perspectives on Learning and Clinical Practice Improvement for Diabetes in the Hospital: A Review of Educational Interventions for Providers

Cited by 10 publications

References 67 publications

A Multicenter Study Evaluating Perceptions and Knowledge of Inpatient Glycemic Control Among Resident Physicians: Analyzing Themes to Inform and Improve Care

A Multicenter Study Evaluating Perceptions and Knowledge of Inpatient Glycemic Control Among Resident Physicians: Analyzing Themes to Inform and Improve Care

Development, Implementation, and Evaluation of a Physician-Targeted Inpatient Glycemic Management Curriculum

Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes

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