Practice Update: DIABETES

EDITOR’S PICKS 4

Effect of a virtual glucose management service on inpatient glycemic control Annals of Internal Medicine Take-home message • This multisite study investigated whether the implementation of a virtual glucose management service (vGMS) affected glycemic control among inpatients. After implementation of the vGMS, there was a 39% and 36% reduction in the proportion of hyper- and hypoglycemic patients, respectively, compared with pre-implemen- tation. After implementation of vGMS period, there were 15 severe hypoglycemic events compared with 40 events prior to implementation. • The frequency of hypoglycemia and hyperglycemia among inpatients decreased with the implementation of vGMS.

COMMENT By Susan S Braithwaite MD, FACP, FACE T he authors examine the impact of a virtual glycemic manage- ment service (vGMS) among hospitalized glucose-monitored adult non-obstetric patients. The shared EMR of a three-site hospital system was que- ried for daily case findings of patients having two or more glucose readings ≥225 mg/dL, hypoglycemia <70 mg/dL, or insulin pump use. Each morning, a vGMS team member decided whether to create a vGMS note for entry to the EMR. Once created, a note for a given patient was visible to anyone using the EMR, with stipulation that the contents were merely suggestions. After transi- tion, compared with baseline, per 100 hospitalized patients the proportions of hyperglycemic patient-days had declined from 6.6 to 4.0 (RR, 0.61; 0.59– 0.63) and hypoglycemic patient days from 0.78 to 0.49 (RR, 0.64; 0.57–0.70), whereas the proportion of patient days at goal rose from 10.8 to 11.4 (RR, 1.05; 1.03–1.08; P < 0.001 for all comparisons). Readers may wonder about precon- ditions for success and impact upon personalized decision-making. The article describes the team of 3 indi- viduals who created the virtual notes without exploring issues of minimum acceptable qualifications, liability, or mechanisms for remuneration, while suggesting that cost-effectiveness might become demonstrable in a bun- dled care environment. Training of staff by the reporting institutions and a carefully wrought infrastructure were noted, including an inpatient diabetes committee charged with development of policies and procedures for gly- cemic management. The hospital pharmacies accepted only those insu- lin orders delivered through one of the order sets programmed into the EMR. Well-designed order sets not only pro- tect against glycemic adverse events, but also offer menu alternatives that facilitate provider- and patient-level individualization.

Abstract BACKGROUND Inpatient hyperglycemia is com- mon and is linked to adverse patient outcomes. New methods to improve glycemic control are needed. OBJECTIVE To determine whether a virtual glu- cose management service (vGMS) is associated with improved inpatient glycemic control. DESIGN Cross-sectional analyses of three 12-month periods (pre-vGMS, transition, and vGMS) between 1 June 2012 and 31 May 2015. SETTING 3 University of California, San Francisco, hospitals. PATIENTS All nonobstetric adult inpatients who underwent point-of-care glucose testing. INTERVENTION Hospitalized adult patients with 2 or more glucose values of 12.5 mmol/L or

Well-designed order sets not only protect against glycemic adverse events, but also offer

menu alternatives that facilitate provider- and patient-level individualization.

greater (≥225 mg/dL) (hyperglycemic) and/or a glucose level less than 3.9 mmol/L (<70 mg/dL) (hypoglycemic) in the previous 24 hours were identified using a daily glucose report. Based on review of the insulin/glucose chart in the elec- tronic medical record, recommendations for insulin changes were entered in a vGMS note, which could be seen by all clinicians. MEASUREMENTS Proportion of patient-days clas- sified as hyperglycemic, hypoglycemic, and at-goal (all measurements ≥3.9 and ≤10 mmol/L [≥70 and ≤180 mg/dL] during the pre-vGMS, tran- sition, and vGMS periods). RESULTS The proportion of hyperglycemic patients decreased by 39%, from 6.6 per 100 patient-days in the pre-vGMS period to 4.0 per 100 patient-days in the vGMS period (difference, –2.5 [95% CI, –2.7 to –2.4]). The hypoglycemic proportion in the vGMS period was 36% lower than in the pre-vGMS period (difference, –0.28 [CI, –0.35 to –0.22]). Forty severe hypoglyce- mic events (<2.2 mmol/L [<40 mg/dL]) occurred during the pre-vGMS period compared with 15 during the vGMS period. LIMITATION Information was not collected on patients’ concurrent illnesses and treatment or physicians’ responses to the vGMS notes. CONCLUSION Implementation of the vGMS was associated with decreases in hyperglycemia and hypoglycemia. Association between a virtual glucose man- agement service and glycemic control in hospitalized adult patients: an observational study. Ann Intern Med 2017 May 02:166(9)621- 627, RJ Rushakoff, MM Sullivan, HWMacMaster, et al.

Dr Braithwaite is Clinical Professor of Medicine at the University of Illinois, and President of at Endocrinology Consults and Care in Chicago.

PRACTICEUPDATE DIABETES