Hospital-acquired diabetic complications: How pharmacists can help prevent them

November 10, 2008

Medicare has stopped paying hospitals for blood conditions caused by poor inpatient glycemic control. Health-system pharmacists can help prevent these conditions and reduce uncompensated expenses by insisting on proper protocols.

Key Points

Medicare paid hospitals close to $50 million in 2007 to treat avoidable cases of diabetic ketoacidosis, a life-threatening condition that too often is acquired during a patient's hospital stay.

"Pharmacists should be actively involved in monitoring patients and providing advice or deciding on the appropriate drug therapy," said Kasey K. Thompson, PharmD, director of the practice standards and quality division at the American Society of Health-System Pharmacists.

The cost of inpatient diabetes care is about $40 billion a year. In recognition of that, the American Association of Clinical Endocrinologists (AACE) recently issued a position paper stating improved inpatient blood glucose control is needed to reduce complications and infections, shorten the length of hospital stays, and reduce costs. The AACE says that for every two patients in the hospital with known diabetes, there may be one more patient with newly-noted hyperglycemia.

Blood glucose levels do not have to be extremely high for hyperglycemia to be dangerous. Studies show blood glucose levels consistently as high as 150 mg per dL can be dangerous, possibly resulting in sepsis. This has been known for some time.

A seminal study reported in the Nov. 8, 2001, issue of The New England Journal of Medicine, titled "Intensive Insulin Therapy in Critically Ill Patients," found that "(i)ntensive insulin therapy to maintain blood glucose at or below 110 mg per dL reduces morbidity and mortality among critically ill patients in the surgical intensive care unit."

What's more, according to Almut G. Winterstein, PhD, assistant professor of pharmacy health care administration at the University of Florida Shands Hospital in Gainesville, Fla. Although clinicians have long recognized the need to treat hypoglycemia (low blood glucose), the importance of hyperglycemia (high blood glucose) control for inpatients remains less clear.

"The problem is a fear of overtreating with insulin," she said. "Providers are often more afraid of doing something wrong that results in a problem than doing nothing. But the hyperglycemia that may result from undertreatment is a significant threat. We know now that it is not only the long-term management of blood glucose but the short-term management that can determine morbidity and mortality in patients."

Conditions are preventable

These facts and the CMS action require the implementation of specific guidelines and protocols, with aggressive encouragement by health-system pharmacists, said R. Keith Campbell, PharmD, associate dean and professor of pharmacotherapy at Washington State University.