People with diabetes are hospitalized three times as often as people without diabetes, their cost of care is four times higher and their average stay is two to three days longer.
Additionally, rates of infection, mortality and readmission are 4x, 1.5x and 1.4x greater, respectively.
The question is, are we as a healthcare community doing everything we can to improve these outcomes? Are we paying enough attention to the unique needs of patients with diabetes?
The results of recent nationwide survey indicate we need to do better, and with the shift from volume to value, I would say the question becomes, can we afford not to?
Download the complete survey results here.
The truth is, managing diabetes within our inpatient populations is strife with challenges. This is a large-scale issue and the numbers are growing.
On average, one of every three hospitalized patients -- the majority with diabetes -- requires insulin to control blood glucose during their stay, a medication that although widely prescribed and absolutely necessary is inherently dangerous. Fifty percent of all medication errors involve insulin, including one-third of all fatal medication errors. Insulin is considered a high-alert medication because it has the potential to cause significant patient harm if misused.
Certainly hospitals and health systems face other patient safety challenges, but very few have as substantial an impact on both clinical and financial outcomes. Insulin therapy, whether intravenous or subcutaneous, is both complex and difficult to manage.
When insulin therapy lacks standardization and best practices are not the norm, poorly controlled blood glucose prevails, which can lead to coma, stroke, sepsis, cardiac arrest . . . even death. A recent study by AdventHealth Orlando showed that hospitalized patients who experience severe hypoglycemia (abnormally low blood glucose) incur $10,405 of excess cost per stay and a 61.5% higher readmission rate.
This toll is largely avoidable, but only if hospitals and health systems prioritize glycemic management. The results of this survey underscore there is vast room for improvement.
Download the complete survey results here.
Some of the findings that strike me as concerning include:
- There is consensus among survey respondents that fear of hypoglycemia has a strong influence on the prescribing of insulin, i.e., causes non-prescribing or lack of intensification following hyperglycemia (a state of elevated blood glucose), which can readily compromise patients’ recovery and place them in a highly vulnerable state.
- In spite of abundant evidence demonstrating the limitations and harms of sliding scale insulin, less than a quarter of respondents maintain their hospital uses primarily basal bolus insulin as recommended by the American Diabetes Association, American Association of Clinical Endocrinologists, Society of Hospital Medicine and other authoritative sources. Opinions regarding the top two barriers to full adoption of basal bolus insulin are not related to financial, technical or operational constraints, but rather to knowledge and beliefs, specifically: (1) inadequate prescriber knowledge about basal-bolus-correction regimens, and (2) beliefs that sliding scale is acceptable practice and not harmful. It is my great hope that providers recognize that overcoming these barriers is both achievable and necessary.
- The survey also found that tracking and reporting of hypoglycemia is most typically done solely for a blood glucose threshold of 70 mg/dL, which does not account for severity. Although hypoglycemia characterized as ‘mild-to-moderate’ poses risks and should not be overlooked, hypoglycemia characterized as ‘severe’ -- typically defined by a blood glucose threshold of 40, 50 or 54 mg/dL -- is of far greater consequence and requires a different clinical course of care. If tracking and reporting of ‘severe’ hypoglycemia is not isolated and root cause analysis is not performed, patient safety is jeopardized and opportunities for remediation and improvement are missed.
- Only 58 percent of respondents who work at a hospital with less than 400 beds have a multidisciplinary steering committee that oversees glycemic management and diabetes care. Some form of such a committee is integral to overcoming the issues surrounding fear of hypoglycemia, suboptimal insulin prescribing practices and barriers to full adoption of basal bolus insulin.
- Less than 50 percent of respondents are of the opinion glycemic control is ‘extremely important’ or ‘very important’ to senior clinical executives, and only 25 percent believe this to be true of non-clinical senior executives. Interestingly, when asked whether they believe senior leadership is aware of the safety risks and clinical consequences of hypoglycemia, the overwhelming majority, nearly 85 percent, said yes. The inference is that in spite of being aware of the gravity, senior executives simply do not prioritize glycemic control. As we know, little can be achieved without the buy-in and support of senior leadership.
The good news is, improving the care of hospitalized patients with diabetes and achieving best practices in glycemic management are attainable goals, especially with the aid of purpose-built technologies such as the eGlycemic Management System®.
You are welcome to arrange a complimentary consultation with a Glytec clinical executive to discuss your glycemic management needs and goals. Click here.
Dr. Rhinehart is a diabetologist and Chief Medical Officer of Glytec. He was the first U.S. physician board certified in advanced diabetes management (BC-ADM).