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Evaluation of Glycemic Management in Hospitalized, Non-Critical, Type 2 Diabetic Patients Caitlynn Tabaka, PharmD PGY-1 Pharmacy Resident, CoxHealth, Springfield, MO Midwest Pharmacy Residents Conference May 7 th , 2020 Disclosure Statement

  1. Evaluation of Glycemic Management in Hospitalized, Non-Critical, Type 2 Diabetic Patients Caitlynn Tabaka, PharmD PGY-1 Pharmacy Resident, CoxHealth, Springfield, MO Midwest Pharmacy Residents Conference May 7 th , 2020

  2. Disclosure Statement The speaker has no conflicts of interest to  disclose

  3. Learning Objective • To assess for appropriate glycemic management in hospitalized, non- critical, type 2 diabetic patients

  4. Cox Medical Center South  650-bed hospital in Southwest Missouri  Level-1 trauma center  Level-1 stroke center

  5. Diabetes 38% of all patients in the 34.2 million United States people have experience diabetes in the hyperglycemia United States during their hospitalization Lansang M, et al. Cleve Clin J Med . 2016; 83:S34-43 Mendez C, et al. Curr Diab Rep . 2016; 16(1):10

  6. American Diabetes Association (ADA) Guidelines • Blood glucose level > 140 Hyperglycemia mg/dL Hypoglycemia • Blood glucose level < 70 mg/dL Goal Glucose • 140 -180 mg/dL Range Ideal Insulin • Basal-bolus insulin +/- correction Regimens insulin American Diabetes Association Guidelines Umpierrez G, et al. Diabetes Care. 2007;30(9):2181-6

  7. Inpatient Glycemic Management Challenges • Fluctuating courses of acute illness • Unpredictable dietary schedules • Hospitalists varied knowledge and comfort in ordering insulin Complications • Length of stay • Cost • Infection risk • Mortality Bogun M, et al. Clin Ther. 2013;35:724 – 733 Mendez C, et al. Curr Diab Rep . 2016; 16(1):10 Gerard S, et al. J Nurs Care Qual . 2017; 32(3):267-271 Moghissi E, et al. Endocr Pract . 2009; 15(4):353-69 Lansang M, et al. Cleve Clin J Med . 2016; 83:S34-43

  8. Study Design Retrospective chart review Single center January 2019 – June 2019 IRB approved October 2019 IRB: International Review Board

  9. Purpose To evaluate the efficacy and safety of appropriate glycemic management compared to inappropriate glycemic management in hospitalized, non-critical, type 2 diabetic patients

  10. Primary Outcome • Number of patients with blood glucose readings outside of the goal range (70 – 180 mg/dL) in comparative groups

  11. Secondary Outcomes • Rate of hyperglycemic (>180 mg/dL) episodes per patient stay • Rate of hypoglycemic (<70 mg/dL) episodes per patient stay • Mean blood glucose level per patient stay • Standard deviation of blood glucose levels • Mean daily basal-bolus insulin ratio administration • Rate of use of non-insulin glucose lowering agents • Length of stay

  12. Inclusion Criteria ≥18 years old Diagnosis of type 2 diabetes Admission to Cox Medical Center South from January 2019 through June 2019

  13. Exclusion Criteria Discharged within 48 hours of admission Admission to critical care unit Glycemic management consult Order for NPO status ≥24 hours Received an alternate source of nutrition ≥24 hours Diagnosis of end-stage renal disease on hemodialysis Patient did not require or refused insulin during hospital stay On hospice care NPO: Nothing by mouth

  14. Comparator Groups Inappropriate Glycemic Appropriate Glycemic Management (Group 2) Management (Group 1) • Anyone who does not • Initiated on basal and meet “Appropriate bolus insulin within 24 Glycemic hours from admission Management” criteria • Basal insulin: 50-70% • E.g. bolus insulin of total daily required monotherapy • Bolus insulin: 30-50% of total daily required

  15. Study Population ESRD: End stage renal disease NPO: Nothing by mouth DMT2: Diabetes myelitis type 2 ICU: Intensive care unit GM: Glycemic Management

  16. Baseline Characteristics Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=134) Mean Age [Range] 66 [46-80] 68 [41-96] Gender (%) Male 5 (45%) 60 (45%) Female 6 (55%) 74 (55%) Ethnicity (%) African American 2 (18%) 4 (3%) Asian 0 (0%) 1 (1%) Caucasian 8 (73%) 128 (95%) Hispanic 1 (9%) 1 (1%) Mean A1C [Range] 8.6 [6.5-10.9] 7.6 [4.3-12.7] Mean BMI [Range] 28.5 [25.7-50.3] 35.4 [21.7-85] Mean GFR [Range] 69 [26-139] 72 [16-174] Insulin-Naïve (%) 1 (9%) 75 (56%) GM: Glycemic Management

  17. Baseline Characteristics Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=134) Mean Age [Range] 66 [46-80] 68 [41-96] Gender (%) Male 5 (45%) 60 (45%) Female 6 (55%) 74 (55%) Ethnicity (%) African American 2 (18%) 4 (3%) Asian 0 (0%) 1 (1%) Caucasian 8 (73%) 128 (95%) Hispanic 1 (9%) 1 (1%) Mean A1C [Range] 8.6 [6.5-10.9] 7.6 [4.3-12.7] Mean BMI [Range] 28.5 [25.7-50.3] 35.4 [21.7-85] Mean GFR [Range] 69 [26-139] 72 [16-174] Insulin-Naïve (%) 1 (9%) 75 (56%) GM: Glycemic Management

  18. Baseline Characteristics Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=134) Mean Age [Range] 66 [46-80] 68 [41-96] Gender (%) Male 5 (45%) 60 (45%) Female 6 (55%) 74 (55%) Ethnicity (%) African American 2 (18%) 4 (3%) Asian 0 (0%) 1 (1%) Caucasian 8 (73%) 128 (95%) Hispanic 1 (9%) 1 (1%) Mean A1C [Range] 8.6 [6.5-10.9] 7.6 [4.3-12.7] Mean BMI [Range] 28.5 [25.7-50.3] 35.4 [21.7-85] Mean GFR [Range] 69 [26-139] 72 [16-174] Insulin-Naïve (%) 1 (9%) 75 (56%) GM: Glycemic Management

  19. Primary Outcome Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=134) Number of patients with blood glucose 11 (100%) 129 (96%) readings outside of goal range (%) GM: Glycemic Management

  20. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hyperglycemic (>180 10 (91%) 129 (100%) mg/dL) episodes (%) Mean rate of hyperglycemic (>180 13 [2-24] 9 [1-33] mg/dL) episodes per patient stay [range] Range of hyperglycemic 181-494 181-438 (>180 mg/dL) episodes GM: Glycemic Management

  21. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hyperglycemic (>180 10 (91%) 129 (100%) mg/dL) episodes (%) Mean rate of hyperglycemic (>180 13 [2-24] 9 [1-33] mg/dL) episodes per patient stay [range] Range of hyperglycemic 181-494 181-438 (>180 mg/dL) episodes GM: Glycemic Management

  22. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hyperglycemic (>180 10 (91%) 129 (100%) mg/dL) episodes (%) Mean rate of hyperglycemic (>180 13 [2-24] 9 [1-33] mg/dL) episodes per patient stay [range] Range of hyperglycemic 181-494 181-438 (>180 mg/dL) episodes GM: Glycemic Management

  23. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hyperglycemic (>180 10 (91%) 129 (100%) mg/dL) episodes (%) Mean rate of hyperglycemic (>180 13 [2-24] 9 [1-33] mg/dL) episodes per patient stay [range] Range of hyperglycemic 181-494 181-438 (>180 mg/dL) episodes GM: Glycemic Management

  24. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hypoglycemic (<70 mg/dL) 1 (9%) 15 (12%) episodes (%) Mean rate of hypoglycemic (<70 mg/dL) episodes per patient stay 8 [8] 2 [1-6] [range] Range of hypoglycemic (<69 51-67 39-69 mg/dL) episodes

  25. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hypoglycemic (<70 mg/dL) 1 (9%) 15 (12%) episodes (%) Mean rate of hypoglycemic (<70 mg/dL) episodes per patient stay 8 [8] 2 [1-6] [range] Range of hypoglycemic (<69 51-67 39-69 mg/dL) episodes

  26. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hypoglycemic (<70 mg/dL) 1 (9%) 15 (12%) episodes (%) Mean rate of hypoglycemic (<70 mg/dL) episodes per patient stay 8 [8] 2 [1-6] [range] Range of hypoglycemic (<69 51-67 39-69 mg/dL) episodes

  27. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=129) Number of patients with hypoglycemic (<70 mg/dL) 1 (9%) 15 (12%) episodes (%) Mean rate of hypoglycemic (<70 mg/dL) episodes per patient stay 8 [8] 2 [1-6] [range] Range of hypoglycemic (<69 51-67 39-69 mg/dL) episodes

  28. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=134) Mean blood glucose level 198 [88-310] 175 [107-296] Standard deviation blood 59 39 glucose level Mean daily basal:bolus insulin 60:40 24:76 administration ratio Rate of use of non-insulin 5 (45%) 39 (29%) glucose lowering agents (%) Length of stay [range] 5 [3-9] 6 [3-26] GM: Glycemic Management

  29. Secondary Outcomes Appropriate GM Inappropriate GM Comparator Groups Group 1 (n=11) Group 2 (n=134) Mean blood glucose level 198 [88-310] 175 [107-296] Standard deviation blood 59 39 glucose level Mean daily basal:bolus insulin 60:40 24:76 administration ratio Rate of use of non-insulin 5 (45%) 39 (29%) glucose lowering agents (%) Length of stay [range] 5 [3-9] 6 [3-26] GM: Glycemic Management

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