Diabetes control: Closing the gap

Believe it or not, one in four hospitalized patients has diabetes and the annual cost of treating inpatient diabetes in the United States has reached $40 billion. These stunning statistics represent only two of the reasons why the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) joined forces in late January to develop a position statement outlining strategies for improving inpatient glycemic control.

"People with diabetes and high blood sugar are an increasing percentage of hospitalized patients with serious problems that require special attention," said Rhoda H. Cobin, M.D., at the Inpatient Diabetes and Glycemic Control: A Call to Action Conference, where the new guidelines were developed. Cobin is president of the American College of Endocrinology.

In the new document, "the consensus panel strongly recommends identification of elevated blood sugars in all hospitalized patients," said Vivian A. Fonseca, M.D., a member of the writing panel and director of the diabetes program at Tulane University Medical Center. "There is much evidence now that elevated blood sugar, even without prior diabetes, is a risk factor for increased mortality and morbidity and systems should be put in place to identify those patients who are at risk." He explained that most hospitalized patients already have their blood glucose tested, but often nothing is done if an elevated level is found.

According to the report, for every two patients in the hospital with known diabetes, there may be one with newly observed hyperglycemia. The authors agreed that this is a golden opportunity for hospital workers to identify new cases of diabetes that otherwise would go undetected.

Once identified, hyperglycemia should be vigorously treated to improve outcomes, said the position statement. "It is clear that no one individual can handle this in a hospitalwide setting," said Fonseca. Therefore a multidisciplinary team approach should be created in all hospitals to effectively treat these patients.

Other strategies mentioned include developing structured protocols for aggressive control of blood glucose and the proper use of subcutaneous and intravenous insulin in intensive care units and other hospital settings. Providing educational programs for all hospital personnel involved in the care of diabetes patients is another essential component to successful treatment, according to the panel.

"When subcutaneous insulin is administered, it should be in the most physiologic way possible to achieve the best control," said Alan J. Garber, M.D., Ph.D., chair of the position statement writing panel. "We must mimic the way insulin is secreted in nondiabetics." He said that hypoglycemia may be unavoidable as a result of aggressive treatment, but it is usually transient and easily treated.

Finally, the committee recommended that the National Diabetes Quality Improvement Alliance develop and submit performance measures for managing inpatient hyperglycemia to the National Quality Forum for the approval process, which would establish these measures as standards for the nation.

The AACE/ADA position statement can be accessed at http://www.aace.com/ or http://www.diabetes.org/.