There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.
“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.
He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.
No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.
Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.
Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.
Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.
In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.
In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”
“How much?” I asked.
“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.
He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.
Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.
Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.
Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.
“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.
I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.
“I’ll be there,” the cardiologist said.
Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.
The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.
Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.
The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.
Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.
This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.
When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.
This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.
One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.
“Medicine has become a pig trough here,” he muttered.
Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.
We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.
“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.
How about doing the opposite and increasing the role of big insurance companies?
“What good would that do?” Dyke asked.
The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”
He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.
This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.
Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.
Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.
In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future. ♦
Thursday, June 18, 2009
Sunday, May 24, 2009
Hospitalized Patients With High Blood Glucose
New Guidelines Address Treatment of Hospitalized Patients With High Blood Glucose Levels CME/CE
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP
CME/CE Released: 05/11/2009; Valid for credit through 05/11/2010
May 11, 2009 — A consensus statement of the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) issues clinical recommendations on the proper treatment of hospitalized patients with high blood glucose levels.
The new guidelines, which target healthcare professionals, supporting staff, hospital administrators, and others involved in improved management of hyperglycemia in inpatient settings, are published in the May/June issue of Endocrine Practice and in the May issue of Diabetes Care.
"Although the costs of illness-related stress hyperglycemia are not known, they are likely to be considerable in light of the poor prognosis of such patients," write Etie S. Moghissi, MD, FACP, FACE, from the University of California in Los Angeles, and colleagues. "There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials (RCTs) suggested that intensive treatment of hyperglycemia improved hospital outcomes."
In 2004, the American College of Endocrinology (ACE) and the AACE, in collaboration with the ADA and other medical organizations, developed recommendations for treatment of inpatient hyperglycemia. These guidelines generally endorsed tight glycemic control in critical care units. In 2005, the ADA annual Standards of Medical Care included recommendations for treatment of inpatient hyperglycemia. In 2006, the ACE and ADA collaborated on a joint "Call to Action" for inpatient glycemic control, highlighting several barriers to systematic implementation in hospitals.
Questions to Be Considered
The main objectives of the AACE and ADA in preparing this updated consensus statement were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. After extensive review of the most current literature, members of the consensus panel considered the following questions:
1. Does improving glycemic control for inpatients with hyperglycemia improve clinical outcomes?
2. What glycemic targets should be recommended for different patient populations?
3. In specific clinical situations, which available treatment options can safely and effectively achieve optimal glycemic targets?
4. What safety issues are associated with inpatient management of hyperglycemia?
5. What systems need to be in place to implement these recommendations?
6. Is it cost-effective to treat hyperglycemia in hospitalized patients?
7. What are the best strategies to shift management of hyperglycemia to outpatient care?
8. What additional research is needed?
Recommendations for Critically Ill Patients
Specific clinical recommendations for critically ill patients are as follows:
• For treatment of persistent hyperglycemia, beginning at a threshold of no greater than 180 mg/dL (10.0 mmol/L), insulin therapy should be started.
• For most critically ill patients, a glucose range of 140 to 180 mg/dL (7.8 - 10.0 mmol/L) is recommended once insulin therapy has been started.
• To achieve and maintain glycemic control in critically ill patients, the preferred method is intravenous insulin infusions.
• Validated insulin infusion protocols that are shown to be safe and effective and to have low rates of hypoglycemia are recommended.
• To reduce hypoglycemia and to achieve optimal glucose control, frequent glucose monitoring is essential in patients receiving intravenous insulin.
Recommendations for Patients Who Are Not Critically Ill
Specific clinical recommendations for noncritically ill patients are as follows:
• For most noncritically ill patients receiving insulin therapy, the premeal blood glucose target should generally be less than 140 mg/dL (< 7.8 mmol/L), and random blood glucose levels should be less than 180 mg/dL (< 10.0 mmol/L), provided these targets can be safely achieved.
• In stable patients in whom tight glycemic control was previously achieved, more rigorous targets may be appropriate.
• In terminally ill patients or in those with severe comorbidities, less stringent targets may be appropriate.
• For achieving and maintaining glucose control, the preferred method is scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components.
• Prolonged treatment with sliding-scale insulin as the only therapeutic agent is discouraged.
• For most hospitalized patients who require treatment of hyperglycemia, noninsulin antihyperglycemic agents are not appropriate.
• Day-to-day decisions concerning treatment of hyperglycemia must be based on clinical judgment and ongoing evaluation of clinical status.
Safety Recommendations
Specific recommendations geared toward improving safety in management of inpatient hyperglycemia are as follows:
• Major safety issues include overtreatment and undertreatment of hyperglycemia.
• Hospital staff must be educated to engage the support of those involved in the care of inpatients with hyperglycemia.
• In patients with anemia, polycythemia, hypoperfusion, or use of some medications, caution is needed when interpreting results of point-of-care glucose meters.
• To promote a rational systems approach to inpatient glycemic management, buy-in and financial support from hospital administration are required.
The guidelines also propose a selected number of research questions and topics to guide the management of inpatient hyperglycemia in different hospital settings.
"Appropriate inpatient management of hyperglycemia is cost-effective," the guidelines authors conclude. "Preparation for transition to the outpatient setting should begin at the time of hospital admission. Discharge planning, patient education, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient glycemic management."
Some of the guidelines authors have disclosed various financial relationships with sanofi-aventis U.S. LLC; Amylin Pharmaceuticals, Inc;Takeda Pharmaceuticals North America, Inc; AstraZeneca; GlaxoSmithKline; Johnson & Johnson Services, Inc; Eli Lilly & Co; Medtronic, Inc; Novo Nordisk A/S; Halozyme Therapeutics; MannKind Corporation; Abbott Laboratories; F. Hoffman La Roche Ltd. (Roche); and/or Merck & Co.
Endocr Pract. 2009;15:1-15.
Diabetes Care. Published online May 8, 2009.
Clinical Context
Hyperglycemia is common in the inpatient setting, and reducing high blood glucose levels is associated with better patient outcomes. However, a study by Finfer and colleagues, which was published in the March 26, 2009, issue of The New England Journal of Medicine, found that more intense glucose treatment could actually result in higher mortality rates in critically ill patients.
Compared with a cohort of patients randomly assigned to a target blood glucose level of 180 mg/dL or less, participants randomly selected to target glucose levels of 81 to 108 mg/dL experienced a 14% increase in the risk for death. Rates of hypoglycemia were much higher in the intensive vs standard-control group, and intensive therapy did not significantly alter the duration of hospital stay, the need for renal replacement therapy, or the number of days of mechanical ventilation.
The current review examines the sum of evidence for the management of hyperglycemia in inpatient settings and makes treatment recommendations.
Study Highlights
* Treatment of hyperglycemia is associated with reduced rates of wound infection after cardiothoracic surgery, lower rates of infection and lower poor neurologic outcomes in patients with traumatic brain injury, and reduced rates of congestive heart failure after acute myocardial infarction.
* The current recommendations state that hyperglycemia be treated at a threshold of 180 mg/dL in critically ill patients. The target glucose level should be between 140 and 180 mg/dL.
* Intravenous insulin infusion is the preferred means of treatment of hyperglycemia in critically ill patients.
* There is less clinical evidence regarding the treatment of hyperglycemia in hospitalized patients who are not critically ill, so the current recommendations regarding this subject are based on clinical experience and judgment. The authors suggest that premeal glucose targets should be less than 140 mg/dL, and random blood glucose values should be less than 180 mg/dL.
* Less stringent treatment criteria may be appropriate for terminally ill patients and those with severe comorbidities.
* To avoid hypoglycemia in patients without critical illness, clinicians should consider altering the insulin regimen if blood glucose levels decline below 100 mg/dL.
* The ideal treatment of hyperglycemia in noncritically ill hospitalized patients should involve basal, nutritional, and correction insulin delivered subcutaneously.
* Treatment with sliding-scale insulin therapy alone is discouraged, and noninsulin antihyperglycemic agents do not have a significant role among inpatients.
* Hyperglycemia develops in many patients receiving corticosteroids. These patients should receive at least 48 hours of blood glucose monitoring and treatment as appropriate.
* In patients receiving continuous enteral or parenteral nutrition, blood glucose monitoring should be performed every 4 to 6 hours. Glucose testing should be performed every 30 minutes to 2 hours in patients receiving intravenous insulin infusions.
* Appropriate inpatient management of hyperglycemia is cost-effective.
* Multidisciplinary teams can establish and enforce local hospital recommendations regarding inpatient treatment of hyperglycemia, and preprinted order sets and computerized ordering systems can improve guideline adherence.
Clinical Implications
* A recent study found a higher risk for death associated with more intensive treatment of hyperglycemia in critically ill patients.
* The current recommendations suggest that antihyperglycemic treatment should begin when the blood glucose level reaches 180 mg/dL among critically ill inpatients, and blood glucose levels should be maintained between 140 and 180 mg/dL in these patients. Blood glucose levels should be maintained below 140 mg/dL before meals and below 180 mg/dL at random times among other inpatients.
CME/CE Test
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP
CME/CE Released: 05/11/2009; Valid for credit through 05/11/2010
May 11, 2009 — A consensus statement of the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) issues clinical recommendations on the proper treatment of hospitalized patients with high blood glucose levels.
The new guidelines, which target healthcare professionals, supporting staff, hospital administrators, and others involved in improved management of hyperglycemia in inpatient settings, are published in the May/June issue of Endocrine Practice and in the May issue of Diabetes Care.
"Although the costs of illness-related stress hyperglycemia are not known, they are likely to be considerable in light of the poor prognosis of such patients," write Etie S. Moghissi, MD, FACP, FACE, from the University of California in Los Angeles, and colleagues. "There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials (RCTs) suggested that intensive treatment of hyperglycemia improved hospital outcomes."
In 2004, the American College of Endocrinology (ACE) and the AACE, in collaboration with the ADA and other medical organizations, developed recommendations for treatment of inpatient hyperglycemia. These guidelines generally endorsed tight glycemic control in critical care units. In 2005, the ADA annual Standards of Medical Care included recommendations for treatment of inpatient hyperglycemia. In 2006, the ACE and ADA collaborated on a joint "Call to Action" for inpatient glycemic control, highlighting several barriers to systematic implementation in hospitals.
Questions to Be Considered
The main objectives of the AACE and ADA in preparing this updated consensus statement were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. After extensive review of the most current literature, members of the consensus panel considered the following questions:
1. Does improving glycemic control for inpatients with hyperglycemia improve clinical outcomes?
2. What glycemic targets should be recommended for different patient populations?
3. In specific clinical situations, which available treatment options can safely and effectively achieve optimal glycemic targets?
4. What safety issues are associated with inpatient management of hyperglycemia?
5. What systems need to be in place to implement these recommendations?
6. Is it cost-effective to treat hyperglycemia in hospitalized patients?
7. What are the best strategies to shift management of hyperglycemia to outpatient care?
8. What additional research is needed?
Recommendations for Critically Ill Patients
Specific clinical recommendations for critically ill patients are as follows:
• For treatment of persistent hyperglycemia, beginning at a threshold of no greater than 180 mg/dL (10.0 mmol/L), insulin therapy should be started.
• For most critically ill patients, a glucose range of 140 to 180 mg/dL (7.8 - 10.0 mmol/L) is recommended once insulin therapy has been started.
• To achieve and maintain glycemic control in critically ill patients, the preferred method is intravenous insulin infusions.
• Validated insulin infusion protocols that are shown to be safe and effective and to have low rates of hypoglycemia are recommended.
• To reduce hypoglycemia and to achieve optimal glucose control, frequent glucose monitoring is essential in patients receiving intravenous insulin.
Recommendations for Patients Who Are Not Critically Ill
Specific clinical recommendations for noncritically ill patients are as follows:
• For most noncritically ill patients receiving insulin therapy, the premeal blood glucose target should generally be less than 140 mg/dL (< 7.8 mmol/L), and random blood glucose levels should be less than 180 mg/dL (< 10.0 mmol/L), provided these targets can be safely achieved.
• In stable patients in whom tight glycemic control was previously achieved, more rigorous targets may be appropriate.
• In terminally ill patients or in those with severe comorbidities, less stringent targets may be appropriate.
• For achieving and maintaining glucose control, the preferred method is scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components.
• Prolonged treatment with sliding-scale insulin as the only therapeutic agent is discouraged.
• For most hospitalized patients who require treatment of hyperglycemia, noninsulin antihyperglycemic agents are not appropriate.
• Day-to-day decisions concerning treatment of hyperglycemia must be based on clinical judgment and ongoing evaluation of clinical status.
Safety Recommendations
Specific recommendations geared toward improving safety in management of inpatient hyperglycemia are as follows:
• Major safety issues include overtreatment and undertreatment of hyperglycemia.
• Hospital staff must be educated to engage the support of those involved in the care of inpatients with hyperglycemia.
• In patients with anemia, polycythemia, hypoperfusion, or use of some medications, caution is needed when interpreting results of point-of-care glucose meters.
• To promote a rational systems approach to inpatient glycemic management, buy-in and financial support from hospital administration are required.
The guidelines also propose a selected number of research questions and topics to guide the management of inpatient hyperglycemia in different hospital settings.
"Appropriate inpatient management of hyperglycemia is cost-effective," the guidelines authors conclude. "Preparation for transition to the outpatient setting should begin at the time of hospital admission. Discharge planning, patient education, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient glycemic management."
Some of the guidelines authors have disclosed various financial relationships with sanofi-aventis U.S. LLC; Amylin Pharmaceuticals, Inc;Takeda Pharmaceuticals North America, Inc; AstraZeneca; GlaxoSmithKline; Johnson & Johnson Services, Inc; Eli Lilly & Co; Medtronic, Inc; Novo Nordisk A/S; Halozyme Therapeutics; MannKind Corporation; Abbott Laboratories; F. Hoffman La Roche Ltd. (Roche); and/or Merck & Co.
Endocr Pract. 2009;15:1-15.
Diabetes Care. Published online May 8, 2009.
Clinical Context
Hyperglycemia is common in the inpatient setting, and reducing high blood glucose levels is associated with better patient outcomes. However, a study by Finfer and colleagues, which was published in the March 26, 2009, issue of The New England Journal of Medicine, found that more intense glucose treatment could actually result in higher mortality rates in critically ill patients.
Compared with a cohort of patients randomly assigned to a target blood glucose level of 180 mg/dL or less, participants randomly selected to target glucose levels of 81 to 108 mg/dL experienced a 14% increase in the risk for death. Rates of hypoglycemia were much higher in the intensive vs standard-control group, and intensive therapy did not significantly alter the duration of hospital stay, the need for renal replacement therapy, or the number of days of mechanical ventilation.
The current review examines the sum of evidence for the management of hyperglycemia in inpatient settings and makes treatment recommendations.
Study Highlights
* Treatment of hyperglycemia is associated with reduced rates of wound infection after cardiothoracic surgery, lower rates of infection and lower poor neurologic outcomes in patients with traumatic brain injury, and reduced rates of congestive heart failure after acute myocardial infarction.
* The current recommendations state that hyperglycemia be treated at a threshold of 180 mg/dL in critically ill patients. The target glucose level should be between 140 and 180 mg/dL.
* Intravenous insulin infusion is the preferred means of treatment of hyperglycemia in critically ill patients.
* There is less clinical evidence regarding the treatment of hyperglycemia in hospitalized patients who are not critically ill, so the current recommendations regarding this subject are based on clinical experience and judgment. The authors suggest that premeal glucose targets should be less than 140 mg/dL, and random blood glucose values should be less than 180 mg/dL.
* Less stringent treatment criteria may be appropriate for terminally ill patients and those with severe comorbidities.
* To avoid hypoglycemia in patients without critical illness, clinicians should consider altering the insulin regimen if blood glucose levels decline below 100 mg/dL.
* The ideal treatment of hyperglycemia in noncritically ill hospitalized patients should involve basal, nutritional, and correction insulin delivered subcutaneously.
* Treatment with sliding-scale insulin therapy alone is discouraged, and noninsulin antihyperglycemic agents do not have a significant role among inpatients.
* Hyperglycemia develops in many patients receiving corticosteroids. These patients should receive at least 48 hours of blood glucose monitoring and treatment as appropriate.
* In patients receiving continuous enteral or parenteral nutrition, blood glucose monitoring should be performed every 4 to 6 hours. Glucose testing should be performed every 30 minutes to 2 hours in patients receiving intravenous insulin infusions.
* Appropriate inpatient management of hyperglycemia is cost-effective.
* Multidisciplinary teams can establish and enforce local hospital recommendations regarding inpatient treatment of hyperglycemia, and preprinted order sets and computerized ordering systems can improve guideline adherence.
Clinical Implications
* A recent study found a higher risk for death associated with more intensive treatment of hyperglycemia in critically ill patients.
* The current recommendations suggest that antihyperglycemic treatment should begin when the blood glucose level reaches 180 mg/dL among critically ill inpatients, and blood glucose levels should be maintained between 140 and 180 mg/dL in these patients. Blood glucose levels should be maintained below 140 mg/dL before meals and below 180 mg/dL at random times among other inpatients.
CME/CE Test
Saturday, May 16, 2009
Saturday, April 11, 2009
mayo never
Dec. 4--Mayo Clinic has again reported deaths related to medical "never events," events health experts believe should "never" occur in the health-care environment.
Each year, up to 98,000 Americans die from medical errors, according to the 1999 Institute of Medicine report called "To Err is Human: Building a Safer Health System."
In 2003, the Minnesota Adverse Health Care Events Act was passed at the urging of hospitals. It requires reporting of never events once each year. The state's goal is to alert hospitals whenever errors are recognized as potentially repeatable.
Increasing attention nationwide has led to increased public disclosure. St. Cloud Hospital, for example, reports blood-infection rates and prices for its most-common treatments.
Mayo Clinic began in May of 2007 to share medical-error summaries with its 31,000-plus Rochester employees four times yearly, rather than the annually as required.
In the 2008 fourth quarter employee newsletter, Mayo reported that during the fourth-quarter reporting period:
--Two patients died after preventable falls. Both experienced brain bleeding before death.
--Two patients were disabled by falls. One received a "two-part" shoulder fracture. The other "sustained a ruptured eye globe." Both required surgery.
"The Mayo Fall Prevention Subcommittee is actively involved in identifying interventions that will minimize harm from falls," the clinic noted.
--Two patients had serious disability associated with medication errors. One still had a "neurological deficit" at discharge.
New protocols and better chemotherapy prescribing supervision were begun. The other patient got inadequate anticoagulation, yielding paralysis on one side of the body.
--Three patients had items still in them after surgery. One had an object in the eye after retinal reattachment surgery.
"The object eventually migrated to the eyelid and was removed," Mayo reported in the employee newsletter. A sponge was retained in another patient, and a guide wire came out of a central venous catheter and had to be removed from a third.
Staff will get hands-on training about the catheters, the clinic reported. Post-surgery item counts are also being emphasized.
--Five patients got pressure ulcers during prolonged hospitalizations. A prevention team was set up.
To put the errors in context, Mayo reported in March that it treated 520,000 patients in 2007.
For more information, visit Postbulletin.com/weblinks.
St. Cloud Hospital, click on "Quality, Safety & Pricing": http://www.centracare.com/hospitals/sch/index.html
To see more of the Post-Bulletin, or to subscribe to the newspaper, go to http://www.postbulletin.com. Copyright (c) 2008, Post-Bulletin, Rochester, Minn. Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.
Each year, up to 98,000 Americans die from medical errors, according to the 1999 Institute of Medicine report called "To Err is Human: Building a Safer Health System."
In 2003, the Minnesota Adverse Health Care Events Act was passed at the urging of hospitals. It requires reporting of never events once each year. The state's goal is to alert hospitals whenever errors are recognized as potentially repeatable.
Increasing attention nationwide has led to increased public disclosure. St. Cloud Hospital, for example, reports blood-infection rates and prices for its most-common treatments.
Mayo Clinic began in May of 2007 to share medical-error summaries with its 31,000-plus Rochester employees four times yearly, rather than the annually as required.
In the 2008 fourth quarter employee newsletter, Mayo reported that during the fourth-quarter reporting period:
--Two patients died after preventable falls. Both experienced brain bleeding before death.
--Two patients were disabled by falls. One received a "two-part" shoulder fracture. The other "sustained a ruptured eye globe." Both required surgery.
"The Mayo Fall Prevention Subcommittee is actively involved in identifying interventions that will minimize harm from falls," the clinic noted.
--Two patients had serious disability associated with medication errors. One still had a "neurological deficit" at discharge.
New protocols and better chemotherapy prescribing supervision were begun. The other patient got inadequate anticoagulation, yielding paralysis on one side of the body.
--Three patients had items still in them after surgery. One had an object in the eye after retinal reattachment surgery.
"The object eventually migrated to the eyelid and was removed," Mayo reported in the employee newsletter. A sponge was retained in another patient, and a guide wire came out of a central venous catheter and had to be removed from a third.
Staff will get hands-on training about the catheters, the clinic reported. Post-surgery item counts are also being emphasized.
--Five patients got pressure ulcers during prolonged hospitalizations. A prevention team was set up.
To put the errors in context, Mayo reported in March that it treated 520,000 patients in 2007.
For more information, visit Postbulletin.com/weblinks.
St. Cloud Hospital, click on "Quality, Safety & Pricing": http://www.centracare.com/hospitals/sch/index.html
To see more of the Post-Bulletin, or to subscribe to the newspaper, go to http://www.postbulletin.com. Copyright (c) 2008, Post-Bulletin, Rochester, Minn. Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.
Wednesday, January 2, 2008
HC in a Mailing Address
Highway Contract.
Private contractors (i.e. non-USPS) employees bid for these mail delivery jobs.
Private contractors (i.e. non-USPS) employees bid for these mail delivery jobs.
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