Long-term improvements in insulin prescribing habits and glycaemic control in medical inpatients associated with the introduction of a standardized educational approach

https://doi.org/10.1016/j.diabres.2009.05.011Get rights and content

Abstract

Background

We carried out an educational strategy to increase physician adherence to 8 recommendations for inpatient evaluation and management of diabetes endorsed by the American Diabetes Association.

Methods

We evaluated physician attitude, barriers and facilitators to incorporate the proposed recommendations into clinical practice. We analyzed the impact of the educational strategy on process-of-care and outcome variables in 138 patients with type 2 diabetes discharged from the internal medicine department before the intervention, at 3-month and at 9-month after the intervention.

Results

After the educational intervention there was a high motivation of physicians to adhere to the proposed recommendations. The intervention caused a significant reduction of insulin administered by sliding scale (50% vs. 7% vs. 3%, P = 0.000), and in the median pre-discharge glycaemic values (185 mg/dL vs. 153 mg/dL vs. 161 mg/dL, P = 0.005), in the three periods, respectively. The use basal-bolus-correction insulin dosage increased in postintervention periods (17% vs. 85% vs. 99%, P = 0.004). Hypoglycaemia (glycaemia <60 mg/dL) episodes were similar among the three periods (0.30% vs. 0.70% vs. 1.07%, P = 0.10). The intervention required improvements to promote haemoglobinA1c ordering on admission and diabetes intensification therapy at discharge when needed.

Conclusion

Our educational strategy improved physician adoption of practice guidelines.

Introduction

Most hospitalizations for patients with diabetes are due to aggravation of underlying conditions, and hyperglycaemia management usually does not constitute a treatment focus during hospital admission [1]. However, inpatient hyperglycaemia has been associated with nosocomial infections, increased mortality, and increased length of stay [2].

At our institution, prior to March 2008, the standardized approach to control of hyperglycaemia in hospitalized patients was based on administration of subcutaneous regular insulin as sliding scale dosing. Upon admission diabetic patients received a predetermined amount of subcutaneous regular insulin, usually beginning with 2 units for blood glucose >150 or 200 mg/dL. The dose was increased by 2 units for every 50-mg/dL increase in blood glucose. Previous outpatient diabetes therapy was commonly maintained during admission. A limited number of physicians prescribed insulin as “basal-bolus-correction” approach, but none consistently followed available consensus guidelines. In April 2008 a standardized educational approach was implemented to disseminate the recommendations of the American Diabetes Association for inpatient hyperglycaemia management [3].

The purpose of this study was to evaluate how prescribing habits and glucose control were affected by the implementation of our educational strategy for inpatients in medical wards.

Section snippets

Methods

Our methods have been described in detail elsewhere [4] and are summarized here. The Hospital Marina Baixa Institutional Review Board approved the study.

Physicians attitude, barriers and facilitators

A total of 33 physicians completed the questionnaire for a response rate of 46%. Median and interquartilic range [IQR] of 5-point Likert scale for every item were: (1) willingness to use insulin as basal-bolus-correction dosage (median 5; IQR: 5–5); (2) perception of better glycaemic control with basal-bolus-correction insulin dosage (median 4; IQR: 4–5); (3) concerns about the greater risk of hypoglycaemia with basal-bolus-correction insulin dosage (median 4; IQR: 2.5–4); (4) simplicity of the

Effectiveness of the standardized educational approach

We found that our educational intervention was effective in improving glycaemic control of patients admitted to internal medicine wards. Particularly, after the education intervention we identified a high motivation of health professionals to adhere to the American Diabetes Association Clinical Practice Guideline and we assessed barriers and facilitators for the applicability of the recommendations. Along the study period we observed a dramatically reduction in the use of insulin administered

Learning points

  • 1.

    Despite current guidelines, administration of subcutaneous regular insulin as sliding scale dosing remains as the standard approach for glycaemia management in hospitalized patients in many institutions.

  • 2.

    Improving glucose control by standard protocols based on insulin administration as basal-bolus-correction dosage is feasible and safe.

  • 3.

    Protocol implementation caused significant improvements in blood glucose control without increasing the risk of hypoglycaemia.

  • 4.

    It is necessary to promote

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgements

We thank the physicians and healthcare workers of the Internal Medicine and Emergency Medicine Departments for their willingness to participate in this research Project.

Contributions. JE conceived and designed the study, undertook the statistical analysis and drafted the paper; RC assisted in study design and reviewed the paper; TL, AL and JTA assisted in study design, collected data and reviewed the paper; JFND helped draft the paper. All authors reviewed and approved the final manuscript.

References (14)

  • S.H. Roman et al.

    Windows of opportunity to improve diabetes care when patients with diabetes are hospitalized for other conditions

    Diabetes Care

    (2001)
  • S.E. Inzucchi

    Clinical practice. Management of hyperglycaemia in the hospital setting

    N. Engl. J. Med.

    (2006)
  • American Diabetes Association

    Standards of medical care in diabetes

    Diabetes Care

    (2008)
  • J. Ena et al.

    Impact of an educational program to improve glycemic control in patients hospitalized in internal medicine wards

    Av Diabetol

    (2008)
  • W. D’Hoore et al.

    Risk adjustment in outcome assessment: the Charlson comorbidity index

    Methods Inf. Med.

    (1993)
  • W.A. Knaus et al.

    APACHE II: a severity of disease classification system

    Crit. Care Med.

    (1985)
  • M.S. Kirkman et al.

    Impact of a program to improve adherence to diabetes guidelines by primary care physicians

    Diabetes Care

    (2002)
There are more references available in the full text version of this article.

Cited by (25)

  • Perspectives on learning and clinical practice improvement for diabetes in the hospital: A review of educational interventions for providers

    2017, Endocrine Practice
    Citation Excerpt :

    Notoriously complex glucose management scenarios, such as corticosteroid-associated hyperglycemia and pre-operative care, seem to benefit from the use of an assistive device to provide information to clinicians and guide their practice (39). The failure to sustain clinical goals achieved as time after education elapses (40) raises the concern for the reliability and accountability of processes needed to maintain quality of patient care. Further, knowledge appears to plateau among more advanced residents and among faculty (44).

  • Transcultural Endocrinology: Adapting Type-2 Diabetes Guidelines on a Global Scale

    2016, Endocrinology and Metabolism Clinics of North America
    Citation Excerpt :

    Examples of CPG transculturalizations in different regions of the world are presented in Table 6. Most of these transculturalizations acknowledge the difficulties associated with implementation and the potential benefits of overcoming barriers.93–95 Common barriers in these examples include fragmentation of the health care system,96 need to adapt to chronic disease management,97,98 and education.99

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

    2015, European Journal of Internal Medicine
    Citation Excerpt :

    It has been addressed that a determination of HbA1c is important both to diagnose stress hyperglycemia and to guide treatment for hyperglycemia when the patient is going to be discharged [24]. However, only a minority of our patients had a recent value of HbA1c, an important limitation that it has been previously notified in Spanish hospitals [16,17]. During hospitalization the monitoring of capillary glucose should be matched to patient's nutritional intake and medication regimen [10,14].

View all citing articles on Scopus
View full text