Improving inpatient diabetes care consensus conference - day one notes!

We’re here in DC at the Improving Inpatient Diabetes Care: a Call to Action Conference. Co-sponsored by ACE, the AACE, and the ADA, this two-day conference will culminate in the writing of a consensus statement on inpatient care for patients with diabetes. There were some fabulous moments today, below which we really just want to talk, just let me know.

1.     Dr. Greet Van den Berghe unveiled new data:

·       The legendary Dr. Van den Berghe spoke first, appropriately, reviewing her data on intensive control in both surgical and medical ICUs. She emphasized that the difference in blood glucose levels between the intensive insulin therapy group and the non-intensive group was relatively small: the conventionally managed group had blood glucose levels around 150 mg/dL, not at 300 mg/dL.

·       New four-year follow-up data showed that the benefits of tight glucose control (TGC) were maintained long-term: even at four years, there was a lowering of mortality in the TGC group (p=0.006).

·       While the 2001 study was in the surgical ICU, it was not clear that these results would apply to the medical ICU as well. The success of TGC in the surgical ICU was due to prevention in complications, such as blood stream infections, acute renal failure causing dialysis, etc. The population of a medical ICU is very different, often patients with HIV, cancer, or end-stage diseases.

·       One fascinating aspect of Dr. Van den Berghe’s talk was her discussion of separating blood glucose and insulin as variables. She said that when she conducted her landmark 2001 trial, her hypothesis was that insulin deficiency might affect mortality, but what she found was that intensive insulin therapy benefited patients because of its impact on blood glucose levels. Although it is not possible to isolate the two variables in human experiments, investigators in her lab used rabbits to prove this conclusively: the study had four arms, two with hyperglycemia and two with euglycemia, and one of each of those with hyperinsulinemia. What they found was that both arms with euglycemia did well, and the arm with high insulin levels and high blood glucose levels actually did the worst in terms of outcomes.

·       The effects were quantified toward the close of the time - very impressive indeed!

2.     Anthony Furnary stayed up all night to crunch complete 2005 data and wows audience:

·       Dr. Furnary wowed with his data from Portland, now totaling 5,619 patients (www.portlandprotocol.com)

·       He had four lessons from “trends in glycemic control”

a.     Insulin talks, glucose walks

b.     Hyperglycemia kills

c.     Insulin saves

d.     Time is on our side

·       He made it clear that he thought glycemia was the villain, not diabetes

·       Furnary emphasized duration of therapy is very key – this is about getting the patient healthy long term, not just in the ICU. He was very convincing in his belief that good glucose control is about the glucose levels, not about insulin levels – insulin is a mechanism to get there.

3.     JCAHO Executive VP Charles Mowell presented on the Joint Commission’s interest in diabetes:

·       JCAHO sounds like it has great opportunity to influence how hospitals move forward on the intensive insulinization front by making recommendations as to how the hospital should move forward on the quality front.

·       At present, they will only make recommendations, not requirements, which was a disappointment to some, like Dr. Irl Hirsch. However, others like AACE board member Paul Jellinger thought it was terrific to see JCAHO moving ahead with even preliminary recommendations. He believes JCAHO will make recommendations requirements if they aren’t taken up.

4.     A financial case for tight glycemic control in inpatients:

·       The second session of the day featured three speakers addressing the question “Is cost a barrier to improved inpatient care?” Dr. Thomas Balcezak, a hospital administrator, spoke on “New clinical initiatives: the view from hospital administration,” emphasizing that hospital administrators are concerned with the public’s trust, public reporting, pay for performance, patient capacity, and financial solvency. He highlighted an initiative his hospital undertook in the realm of diabetes.

·       Between 1996 and 2003, discharges of patients with diabetes were up 26%, compared with a 19% increase in discharges overall. In most patients with diabetes who were coming to the hospital, diabetes was a comorbidity, not the cause of hospitalization. While the length of stay (LOS) for the hospital overall had fallen 2.5% down to 6.55 days, there was a full day’s difference between all patients and those patients with diabetes.

·       In that time period, there had been a 30% decrease in overall mortality (2.79% to 2.22%), but an increase in mortality for patients with diabetes that translated to 40 excess deaths per year.

·      He estimated the net savings/revenue to be $439,000 over three years, and the expense to be $225,750, for a diabetes team (not all members FTE).