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Effect of Preoperative Diabetes Management on Glycemic Control and Clinical Outcomes After Elective Surgery

Garg, Rajesh; Schuman, Brooke; Bader, Angela; Hurwitz, Shelley; Turchin, Alexander; Underwood, Patricia; Metzger, Cheyenne; Rein, Raquel; Lortie, Meghan
OBJECTIVE:The aim of this study was to evaluate whether preoperative diabetes management can improve glycemic control and clinical outcomes after elective surgery. BACKGROUND:There is lack of data on the importance of diabetes treatment before elective surgery. Diabetes is often ignored before surgery and aggressively treated afterwards. METHODS:Patients with diabetes were identified and treated proactively before their scheduled surgeries. Data for all elective surgeries over 2 years before and 2 years after implementation of the program were collected. RESULTS:Out of 31,392 patients undergoing first surgery, 3909 had diabetes; 2072 before and 1835 after the program. Mean blood glucose on the day of surgery was 146.4 ± 51.9 mg/dL before and 139.9 ± 45.6 mg/dL after the program (P = 0.0028). Proportion of patients seen by the inpatient diabetes team increased. Mean blood glucose during hospital stay was 166.7 ± 42.9 mg/dL before and 158.3 ± 46.6 mg/dL after program (P < 0.0001). The proportion of patients with hypoglycemic episodes (<50 mg/dL) was 4.93% before and 2.48% after the program (P < 0.0001). Length of hospital stay (LOS) decreased among patients with diabetes (4.8 ± 5.3 to 4.6 ± 4.3 days; P = 0.01) and remained unchanged among patients without diabetes (4.0 ± 4.5 and 4.1 ± 4.8, respectively; P = 0.42). Changes in intravenous antibiotic use, patients discharged to home, renal insufficiency, myocardial infarction, stroke, and in-hospital mortality were similar among diabetic and nondiabetic groups. CONCLUSIONS:Preoperative and inpatient diabetes management improves glycemic control on the day of surgery and postoperatively and decreases the incidence of hypoglycemia. These changes may eventually improve clinical outcomes. Although statistically significant, the decrease in LOS was of equivocal clinical significance in this study.
PMID: 28549013
ISSN: 1528-1140
CID: 5534662

Effect of follow-up by a hospital diabetes care team on diabetes control at one year after discharge from the hospital

Garg, Rajesh; Hurwitz, Shelley; Rein, Raquel; Schuman, Brooke; Underwood, Patricia; Bhandari, Shreya
AIM/OBJECTIVE:This study was conducted to evaluate the effect of continued follow-up by a hospital diabetes team on HbA1c at 1-year after discharge. METHODS:Adults with HbA1c ≥8% (64mmol/mol), undergoing an elective surgery, were treated in the perioperative period and randomized to continued care (CC) or the usual care (UC) after discharge. Patients in the CC group received weekly to monthly phone calls from a diabetes specialist nurse practitioner (NP) to review their home blood glucose values, diet, exercise, and medications. Patients in the UC group followed with their diabetes care providers. RESULTS:Out of 151 patients, 77 were randomized to the CC group and 74 to the UC group. HbA1c (%) at 1-year was 8.2±1.4 in the CC group and 8.5±1.5 in the UC group (p=NS). Change in HbA1c from baseline was similar between the groups; -0.7±1.4 in the CC versus -0.7±1.5 in the UC group (p=NS). A higher number of calls was not associated with lower HbA1c or reduction in HbA1c. There were 41 insulin-treated patients in the CC group and 53 in the UC group and among them, HbA1c reduction was 0.5±1.5 and 0.6±1.3 respectively (p=NS). CONCLUSIONS:Optimal perioperative treatment of diabetes is associated with an improvement in HbA1c but continued follow-up by a hospital diabetes team after discharge does not have an additional impact on long-term glycemic control. identifier NCT02065050.
PMID: 28898714
ISSN: 1872-8227
CID: 5534672

Safety and efficacy of saxagliptin for glycemic control in non-critically ill hospitalized patients

Garg, Rajesh; Schuman, Brooke; Hurwitz, Shelley; Metzger, Cheyenne; Bhandari, Shreya
OBJECTIVE:To evaluate whether saxagliptin is non-inferior to basal-bolus insulin therapy for glycemic control in patients with controlled type 2 diabetes mellitus (T2DM) admitted to hospital with non-critical illnesses. RESEARCH DESIGN AND METHODS/METHODS:This was an open-label, randomized controlled clinical trial. Patients received either saxagliptin or basal-bolus insulin, both with correctional insulin doses. The main study outcome was the mean daily blood glucose (BG) after the first day of randomization. RESULTS:Of 66 patients completing the study, 33 (age 69±10 years, 40% men) were randomized to saxagliptin and 33 (age 67±10 years, 52% men) to basal-bolus insulin therapy. The mean daily BG was 149.8±22.0 mg/dL in the saxagliptin group and 146.9±30.5 mg/dL in the insulin group (p=0.59). With an observed group difference of 2.9 mg/dL and an a priori margin of 20 mg/dL, inferiority of saxagliptin was rejected in favor of non-inferiority (p=0.007). There was no significant difference in the percentage of high or low BG values. The insulin group received a higher number of insulin injections (2.3±1.7/day vs 1.2±1.9/day; p<0.001) as well as a higher daily insulin dose (13.3±12.9 units/day vs 2.4±3.3 units/day; p<0.001) than did the saxagliptin group. Continuous BG monitoring showed that glycemic variability was lower in the saxagliptin group as compared to the insulin group. Patient satisfaction scores were similar in the two groups. CONCLUSIONS:We conclude that saxagliptin use is non-inferior to basal-bolus insulin in non-critically ill hospitalized patients with T2DM controlled on 0-2 oral agents without insulin. Saxagliptin use may decrease glycemic variability in these patients. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT02182895.
PMID: 28405346
ISSN: 2052-4897
CID: 5534652

Nurse practitioner-mediated intervention for preoperative control of diabetes in elective surgery patients

Garg, Rajesh; Metzger, Cheyenne; Rein, Raquel; Lortie, Meghan; Underwood, Patricia; Hurwitz, Shelley; Bader, Angela; Carbone, Kyle; Schuman, Brooke
PURPOSE/OBJECTIVE:This study evaluated the effect of nurse practitioner (NP) mediated interventions on diabetes control before elective surgery. DATA SOURCES/METHODS:A program was initiated to improve preoperative diabetes control in patients with HbA1c > 8%. The intervention was initially mediated by a physician alone and subsequently changed to involve NPs. The goal of intervention was fasting blood glucose (BG) <200 mg/dL on the day of surgery (DOS). Data were collected before the program (control group), during physician-mediated intervention (phase 1), and during NP-mediated intervention (phase 2). CONCLUSIONS:There were 222 patients in the control group, 226 in phase 1, and 160 in phase 2. Mean BG (mg/dL) on DOS was 171.4 ± 66.5 in control group, 162.6 ± 58.1 in phase 1, and 153.4 ± 46.6 in phase 2 (p = NS for control vs. phase 1 and <0.01 for control vs. phase 2). More patients received an intervention in phase 2 (93%) than in phase 1 (75%). Among those receiving intervention, 87% achieved target BG in phase 2 and 82% in phase 1 (p = NS). Duration of diabetes, baseline HbA1c, time available before surgery, and diabetes intervention were independent predictors of achieving target BG. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:NP-mediated interventions increased access to care and resulted in lower BG levels and may be a good strategy for preoperative diabetes control.
PMID: 27126225
ISSN: 2327-6924
CID: 5534642