Survey Indicates Inpatient Diabetes Care Must be Reformed NOW!

When hospitals do not employ best practices in glucose control for inpatient diabetes care, patients with diabetes experience worse outcomes at greater costs.

A recent landmark survey shows that the current state of inpatient diabetes care and glycemic management needs immediate reform. Approximately one-third of inpatient populations have diabetes, and their cost of care is almost four times greater than those without diabetes. According to this research, greater than 75% of hospitals in the United States follow outdated insulin management protocols that are no longer recommended by the American Diabetes Association, American Association of Clinical Endocrinologists, and Society of Hospital Medicine. As our healthcare model transitions from volume to value-based, we must continuously evaluate and optimize patient services to improve outcomes.

This nationwide study by Glytec included 619 respondents from 408 health-systems. Respondents were as follows: 10.2% physicians, 26.3% diabetes educator or dietitian, 23.7% nursing, 4.2% senior clinical executives, 9.9% pharmacy, 19.2% quality or safety, 4% information technology, and 2.5% operation leaders. The results of this survey, a study by the Agency for Healthcare Research and Quality, and a retrospective analysis by AdventHealth Orlando indicate there are significant financial and health implications associated with improper glucose control within hospitals.

Despite recommendations by the American Diabetes Association, American Association of Clinical Endocrinologists, and Society of Hospital Medicine, nearly one-third of U.S. hospitals lack a multidisciplinary committee that oversees diabetic care. In this survey, respondents ranked their opinion of how important glycemic control is to nurses, physicians, senior clinical executives, and senior non-clinical executives. The summary of survey respondents that believe glycemic control is extremely important or very important to the following personnel is as follows: 70% nurses and physicians, 48% senior clinical executives, and 25% non-clinical senior executives. The consensus is that fear of hypoglycemia causes hesitation in inappropriate insulin prescribing following a hyperglycemic event. Furthermore, 36% believed that the rate of hypoglycemia is too high within their hospital. 85% think that senior leadership understands the health consequences associated with hypoglycemia, but only 67% agree that senior leaders understand the financial implications of improper glycemic control. 33% work in a hospital that does not track and report rates of hypoglycemia. 34% maintain that their facility primarily uses a sliding scale for glycemic control. 

Sliding scale insulin therapy has been proven to be a sub-optimal approach. The American Diabetes Association, American Association of Clinical Endocrinologists, and Society of Hospital Medicine recommend basal-bolus therapy with regular subcutaneous insulin consisting of basal, nutritional, and correctional components. The sliding scale method does not account for key factors such as nutritional status, weight, insulin sensitivity, or resistance. The three main barriers associated with the implementation of the basal-bolus insulin method are inadequate physician knowledge, belief that the sliding scale is an acceptable and safe method, and difficulty coordinating glucose monitoring and insulin administration.

Based on the results of this survey, we are not giving our inpatient diabetic population the best care. To mitigate risk, optimize recovery, and minimize cost, we must standardize protocols based on current recommendations. Replacing sliding scale therapy with basal-bolus therapy and having a multidisciplinary committee that oversees diabetic care will significantly improve inpatient diabetic outcomes. Also, the use of a computer-based support system has shown to be successful at drastically reducing hypoglycemia. Since 50% of all medication errors involve insulin, the use of commercial insulin dosing software is a possible solution to standardize protocols and improve outcomes. The good news is that these risks are modifiable, and we can improve care by utilizing the latest recommendations and standardizing protocols.

Practice Pearls:

From every survey, there is a takeaway and what we have learned is:

• Seventy-five percent of hospitals in the United States follow outdated insulin management protocols that are not recommended.
• Despite recommendations by the American Diabetes Association, American Association of Clinical Endocrinologists, and Society of Hospital Medicine, nearly one-third of U.S. hospitals lack a multidisciplinary committee that oversees diabetic care. 
• Based on the results of this survey, we are not giving our inpatient diabetic population the best care. To mitigate risk, optimize recovery, and minimize cost, we must standardize protocols based on current recommendations.

Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS) 2015.

Gaines M, Tanton, D, Pratley, R. Financial Implications of Poor Glycemic Management & Improvement Strategies for Optimal Outcomes. IHI Annual National Forum on Quality Improvement in Health Care 2018.

Rhinehart, A. Current State of Inpatient Diabetes Care and Glycemic Management, Focus on Insulin Therapy, and Hypoglycemia. A Survey of U.S. Healthcare Professionals 2019.

Kassey James, Pharm.D. Candidate, LECOM School of Pharmacy