Hyperglycemia management in patients admitted to internal medicine in Spain: A point-prevalence survey examining adequacy of glycemic control and guideline adherence

Highlights

• We carried out a national cross sectional study to assess the burden of hyperglycemia in patients admitted to internal medicine.

• We compared inpatient diabetes management to the standards for glucose control recommended in evidence-based guidelines.

• We observed scarce assessment of HbA1c to guide therapy at discharge

• There was high use of non recommended therapy such oral hypoglycaemic agents and sliding scale insulin.

• Inappropriate snacks between meals were used very often in the evening and at night

Abstract

Aims

Despite the increasing prevalence of hospitalized diabetic patients, there are few studies that evaluate the glycemic control and the rate of adherence to clinical practice guidelines for glucose monitoring and management in the hospital setting.

Methods

: Crossover study using one-day surveys of all inpatients admitted to internal medicine wards from voluntary participating hospitals across Spain. Retrospective review of medical records was used to identify patients with hyperglycemia, causes for hospitalization, patients' demographic characteristics, appropriateness of glycemic monitoring and treatment during hospitalization.

Results

Among 5439 hospitalized patients studied there were 1000 (18.4%) with hyperglycemia in 111 participating hospitals. Patients mean age was 76.0 ± 8.5 years (51.6% male). On admission, 91% had known diabetes (disease duration of 10.9 ± 8.5 years), 5% had unknown diabetes and 4% had stress hyperglycemia. The comorbidity index (Charslon score) was 4 (interquartile range: 2 to 6) and 31% showed a high level of disability (Rankin scale). Main infringement in the process of care included lack of a recent HbA1c value (43.7%), use of sliding scale insulin therapy (20.7%), use of oral antidiabetic agents (8.9%), and less than three bedside point-of-care (POC) blood glucose test per day (17%). Glycemic target pre-meal and bedtime were achieved in 47% to 79.5% of POC. The rates of hypoglycemia (< 70 mg/dL and < 50 mg/dL) were 10.3% and 2.4%, respectively.

Conclusions

Our results suggest that there is an important gap between the clinical guidelines and both the management and the grade of glycemic control of diabetic inpatients.

Introduction

Diabetes is one of the fastest growing pandemics in human history. It has been estimated that 14% of the Spanish adult population has diabetes, and this prevalence may double in the coming decades [1]. In parallel, the percentage of patients with diabetes requiring hospitalization has doubled in recent years. Approximately one in four patients admitted to the hospital has a known diagnosis of diabetes [2], [3] and about 30% of patients with diabetes require two or more hospitalizations in any given year [3]. The prevalence of diabetes is higher in elderly patients and residents of long-term-care facilities, in whom diabetes is reported in up to one third of adults aged 65–75 yr and in 40% of those older than 80 yr [4], [5].

Patients with diabetes are more likely to require hospitalization than subjects without diabetes, mostly due to cardiovascular diseases, but also by other processes (cancer, infections, pancreatitis or hip fractures, etc.) [6]. In addition, patients with diabetes have a worse overall prognosis and a higher risk of complications, extended hospitalization and mortality [7], [8].

Different studies have shown that both hyper- and hypoglycemia are associated with more complications and increased mortality in hospitalized patients [9]. In order to guide ongoing glycemic management it is recommended to perform bedside capillary testing before meals and at bedtime in patients who are eating, or every 4–6 h in patients who are receiving nothing by mouth. Treatment should be addressed to a premeal glucose target of less than 140 mg/dL (7.8 mmol/L) and a random blood glucose of less than 180 mg/dL (10.0 mmol/L) for the majority of hospitalized patients in non-critical areas. Due to the risk of severe hyper or hypoglycaemia, the use of sliding scale as the sole method for glycemic control in patients with diabetes has been considered as non-appropriate. The use of subcutaneous insulin therapy consisting on basal or intermediate-acting insulin given once or twice a day in combination with rapid- or short-acting insulin administered before meals in patients who are eating has been considered as the standard of care due to its safety. In addition, a standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol should be implemented to prompt immediate therapy of any recognized hypoglycemia, defined as a blood glucose below 70 mg/dL (3.9 mmol/L). All these standards have been included in a recently published evidence-based guideline and rated as strong recommendations [10].

Few studies have analyzed how are patients with diabetes managed in the hospital and the degree of diabetes control. We carried out the present study to evaluate care based on individualized performance measures and appropriateness of hyperglycemia management in hospitalized patients in the non-critical care setting.