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How Should We Manage Blood Sugar in the Hospital? IHS Leadership Symposium April 20, 2010

How Should We Manage Blood Sugar in the Hospital? IHS Leadership Symposium April 20, 2010. Nate Brady MD, MPH Assistant Medical Director Center for Clinical Transformation Iowa Health System bradyij@ihs.org. Current Diabetes Facts. 7% of Americans are diabetic Age 20 years or older: 9.6%

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How Should We Manage Blood Sugar in the Hospital? IHS Leadership Symposium April 20, 2010

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  1. How Should We Manage Blood Sugar in the Hospital?IHS Leadership SymposiumApril 20, 2010 Nate Brady MD, MPH Assistant Medical Director Center for Clinical Transformation Iowa Health System bradyij@ihs.org

  2. Current Diabetes Facts 7% of Americans are diabetic Age 20 years or older: 9.6% Age 60 years or older: 20.9% Prevalence has risen 5% annually since 1990 Type II DM makes up 90-95% of cases 70% is thought due to weight (???) Source: www.Diabetes.org

  3. Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008 CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available athttp://www.cdc.gov/diabetes/statistics

  4. Age-adjusted percentage of adults aged ≥20 years with diagnosed diabetes, 2007 MMWR 58:1259-1263, 2009

  5. Age-adjusted percentage of adults aged ≥20 years who are obese, 2007 MMWR 58:1259-1263, 2009

  6. Diabetes in Iowa 7% of adults over 20 yrs old 9th lowest rate in the nation (2008) 17% of those over 65 yrs old 29% on insulin at home 73% on oral medications Has stabilized over time IDPH Annual Report BRFSS 2008

  7. Diabetes in Iowa Health System 20-40% of hospitalized patients Varies by diagnosis 41% of COPD patients No consistent approach Conflicting evidence for best practice

  8. Conflicting Evidence 2001 van den Bergh NEJM: intensive glucose control decreases mortality by 42% in ICU patients 2002 Umpierrez J Clin Endo Metab: Hyperglycemia increase risk of death 4X

  9. Hyperglycemia and Mortalityin the ICU (mixed medical/surgical) ~4x ~3x 45 45 45 40 40 40 ~2x 35 35 35 30 30 30 Mortality Rate (%) 25 25 25 20 20 20 15 15 15 10 10 10 5 5 5 0 0 0 80-99 100-119 120-139 140-159 160-179 180-199 200-249 250-299 >300 Mean Glucose Value (mg/dL) N=1826 ICU patients. Krinsley JS. Mayo Clin Proc. 2003;78:1471-1478.

  10. Total Inpatient Mortality 30 20 10 0 16%* Mortality (%) 3.0% 1.7% Normoglycemia Known Diabetes New Hyperglycemia Non ICU Mortality 30 20 10 0 Mortality (%) 10%* 0.8% 1.7% Normoglycemia Known Diabetes New Hyperglycemia ICU Mortality 31%* 30 20 10 0 Mortality (%) 11% 10% Normoglycemia Known Diabetes New Hyperglycemia Hyperglycemia: An Independent Marker of In-Hospital Outcome • Length of stay higher (9.0 vs 4.5 and 5.5 days, respectively) for new hyperglycemia than for normoglycemic or known DM • New hyperglycemia more likely to require ICU than normoglycemic or known DM (29% vs 9% vs 14%, respectively), and to need transitional care after discharge • Trend toward higher rate of infections and neurologic events in the two hyperglycemia groups *P<0.01 Umpierrez GE et al. J Clin Endocrinol Metabol. 2002;87:978-982.

  11. Severe HypOglycemia in Critically Ill Patients: Risk Factors and Outcomes Mortality rate (%) among patients with significant hypoglycemia, matched controls, and no hypoglycemia 60 50 Significant hypoglycemia was associated significantly with an increased risk of mortality (OR, 2.28; 95% CI, 1.41-3.70; P=0.0008) 40 Mortality Rate (%) 30 20 10 0 SH Controls No SH SH, significant hypoglycemia: <2.2 mmol/L; <40 mg/dL. Krinsley JS et al. Crit Care Med. 2007;35:2262-2267.

  12. IHS Campaign to stop SSI Brochures Lectures Posters Local experts engaged Order set development and launch

  13. Adoption of order set

  14. Conflicting Evidence, cont 2008 JAMA Wiener et al: Benefits and Risks of tight glucose control. Meta-analysis showed no difference between intensive vs. good control 2009 NICE-SUGAR NEJM: Intensive vs. good glucose control shows slight INCREASED risk of death

  15. Current Recommendations Glucose Targets Critically ill: 140-180 mg/dL All others: < 140 mg/dL premeal, <180mg/dL other times. Diabetes Care, vol. 33, Supp. I Jan. 2010

  16. Current Recommendations Critically ill: Insulin infusion preferred method All others: Subcutaneous insulin, basal-bolus-correctional preferred method Diabetes Care, vol. 33, Supp. I Jan. 2010

  17. Current Recommendations “A topic that deserves particular attention is the persistent overuse of…sliding scale insulin…prolonged therapy with sliding scale insulin is ineffective." Diabetes Care, vol. 33, Supp. I Jan. 2010

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