June 25, 2013

Pilot Program on Food-Insulin Gap Helpful

This is great news and I hope hospitals are paying attention. Two articles on the same topic – here and here. Again communication is the key and this is often lacking across hospital departments as they think (more like don't) the other department is on top of things. It is surprising what a little cooperation does for the health of patients with diabetes. If you, as the patient, have been allowed to manage your own diabetes, then this study will not benefit you.

This also brings up an idea for another study while thinking about studies. I would like to see a study where the patients that are capable, emphasis on capable, are allowed to manage their own diabetes while in the hospital. Some hospital kitchens are capable of providing a list of the foods on the tray and the carb count of each food item. This would allow those on oral medications to medicate accordingly and those patients on insulin would be able to inject appropriately. This study could be done in hospitals that have an endocrinology department with specialists in diabetes employed by the hospital or attached to the hospital. I dare say that the patients would be more satisfied and not under the stress normally felt when the blood glucose is allowed to run above 180 mg/dl to 220 mg/dl that most hospitals allow.

Back to the study. Dr. Dace Trence, who was not involved in the study, carefully pointed out, “Hospitals may be motivated to do so because they could face penalties from Medicare if they do not. Hyperglycemia in the hospital is now a [national hospital inpatient quality measure], so you can imagine how important it is to try not only to prevent hypoglycemia, but also hyperglycemia."

Considering Dr. Trence's statement adds value to this study and may make hospitals consider this necessary. Shwetha Mallikarjuna, MD, an endocrinology fellow at Southern Illinois University (SIU), Springfield, presented the study at the American Association of Clinical Endocrinologists 2013 Scientific & Clinical Congress in Phoenix.

Often it is the simple interventions are the best medicine, like telling floor nurses that meals are on the way so they can coordinate insulin dosing for hospitalized diabetics.  The study demonstrated that patients received prandial insulin on time with significantly greater frequency when food service and nurses coordinated care (50.4% versus 35.5%). When patients are forced to let hospitals dictate when insulin is injected, the idea of injecting after a meal is a common practice and when a nurse can count carbs and know how many units to inject; this will help prevent a hypoglycemic episode. This is good for the patient and the hospital.

Mallikarjuna did note that their study was limited by a low sample size and low power. She said the study was also limited by poor patient matching. She said that a larger follow-up study is ongoing.

I see a few positives from this study and the potential for good being part of the penalty system being put in place by the Centers for Medicare and Medicaid Services. How much this will benefit patients still is to be determined.

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