Physician's Weekly Article - Conquering Clinical Inertia in Hospitalized Patients With Diabetes

       Aggressive glucose control in hospital settings can have a profound impact on patients with diabetes, but few institutions are making the necessary efforts to identify patients with hyperglycemia and help them reach targeted goals.

      Studies have shown that diabetes increases the risk for complications that predispose patients to hospitalization. The management of diabetes in the hospital is often considered secondary in importance when compared with the condition that prompted the patient’s admission. “Improving the identification of hyperglycemia in hospitals has become an important issue in light of emerging evidence demonstrating that the condition is not necessarily benign,” says Alexander Turchin, MD, MS. “Furthermore, research now suggests that aggressive treatment of diabetes and hyperglycemia may result in reduced mortality and morbidity.”

      Patients who are admitted to the hospital with hyperglycemia either have known diabetes or have no history of the disease prior to admission, according to Dr. Turchin. “We now have data demonstrating that patients who are hyperglycemic after being admitted to the hospital are at the highest risk of having poor outcomes. These individuals are more likely than others to be admitted to the ICU, have higher mortality rates, and accrue lengthier stays in the hospital. They’re also more likely to require more comprehensive treatments.”

      The Impact of Clinical Inertia on ICUs

      Clinical inertia has been defined as an inadequate intensification of therapy by providers, and research has shown that this phenomenon is occurring frequently in the management of hospitalized patients with diabetes. “Hyperglycemia is becoming increasingly prevalent in hospitals, but even low-cost interventions like increasing doses of insulin are not occurring as often as they should in these settings,” Dr. Turchin says. Diabetes is the fourth-leading comorbid condition associated with any hospital discharge in the United States. Research has shown that one in three patients with diabetes will require at least two hospitalizations per year. Furthermore, inpatient stays account for the largest proportion of direct medical expenses incurred by people with diabetes.

      Dr. Turchin says several studies have demonstrated that clinical inertia has a significant impact in ICU settings. “We now have evidence that surgical care ICU patients who have elevated glycemic levels have higher mortality rates, longer ICU stays, more kidney failure, more infections, and other complications. However, patients who were aggressively treated for hyperglycemia can benefit greatly from this intervention.”

      Recent data from medical ICUs, however, have not been as conclusive. “Benefits accrued with respect to ICU stays to all comers when hyperglycemia was aggressively treated,” explains Dr. Turchin, “but recent study results have not had an impact on overall mortality. In fact, patients who had shorter hospital stays had higher mortality rates after receiving intensive control measures than those with longer stays. More investigations are needed to determine which subgroups of hospitalized patients would benefit from intensive treatment of hyperglycemia.”

      Treat Hyperglycemia More Aggressively

      Based on the available data, the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) have created recommendations that stress the importance of treating hospitalized patients with hyperglycemia more aggressively (Table 1). “These recommendations are for patients both inside and outside the ICU,” Dr. Turchin says. “Outside the ICU, these treatments should be directed toward achieving specific goals. Fasting glucose should average about 110 mg/dL and postprandial glucose should be less than 180 mg/dL. For individuals in the ICU, glucose levels should be below 110 mg/dL.”

      A major task for hospitals is to translate the ADA and AACE recommendations into their settings, and Dr. Turchin says that there are barriers to overcome. “Postprandial glucose—which is more likely to be elevated—is infrequently monitored in patients without a known history of diabetes. Fear of hypoglycemia is commonly cited as the reason for lack of intensive insulin therapy, particularly outside of the ICU. Effective, yet resource-intensive protocols have been developed for blood glucose control for critically ill patients, but no comparably effective and safe protocols exist that can be implemented within the staffing constraints of a general inpatient ward. Further work is urgently needed to decrease these barriers for blood glucose control.”

      Cost-Effectiveness Considerations

      Recent retrospective data in non-ICU patient populations have shown that using a diabetes consult team can improve outcomes and shorten lengths of hospital stay for patients with hyperglycemia and diabetes in hospital settings. Unfortunately, the cost of implementing diabetes consult teams can be high, Dr. Turchin says. “There is no good data available assessing the cost effectiveness of implementing models that aim to more aggressively treat hyperglycemia and diabetes in hospitals. While they appear to be effective, diabetes consult teams and other efforts, such as bedside glucose monitoring [Table 2], are costly interventions. We’ll need more data to convince physicians and hospitals that these interventions are necessary, cost effective, and substantially impact patient outcomes."

      Dr. Turchin has indicated to Physician’s Weekly that he has or has had the following financial interest: Ortho-Clinical Diagnostics.