Is all hypoglycaemia treated as equal? An observational study of how the type of diabetes and treatment prescribed prior to admission influences quality of treatment of inpatient hypoglycaemia

Aims: Inpatient hypoglycaemia is common and associated with adverse outcomes. There is often increased vigilance of hypoglycaemia in inpatients with type 1 diabetes (T1DM) compared to type 2 diabetes (T2DM). We aimed to investigate this apparent discrepancy, utilising the time to repeat (TTR) capillary blood glucose (CBG) measurement as a surrogate for engagement with guidelines stating that CBG should be rechecked following intervention within 15 min of an initial CBG of <4 mmol/L. Methods: This is an observational study of inpatient CBG data from 8 hospitals over a 7-year period. A national diabetes registry allowed identification of individual’s diagnosis and diabetes therapy. For each initial (index) CBG, the TTR for individuals with T2DM—on insulin or sulphonylurea—was compared with the TTR for individuals with T1DM, using a t test for significance performed on log(TTR). The median TTR was plotted for each group per index CBG. Results: In total, 1480,335 CBG measurements were obtained. A total of 26,664 were <4 mmol/L. The TTR in T2DM individuals on sulphonylurea was significantly greater than in T1DM individuals where index CBG was ≥2.3 mmol/L (except index CBG 2.6 mmol/L). For T2DM patients receiving insulin significance exists for index CBGs of ≥3.2 mmol/L. Conclusions: This analysis suggests that quality of care of hypoglycaemia varies according to diagnosis and medication. The group with the highest TTR (T2DM sulphonylurea treated) are possibly the clinical group in whom hypoglycaemia is most concerning. These data therefore suggest a need for education and raising awareness within the inpatient nursing staff

Patterns and impact of hypoglycemia, hyperglycemia, and glucose variability on inpatients with insulin-treated cystic fibrosis-related diabetes

Introduction: Mortality in patients with cystic fibrosis-related diabetes (CFRD) is higher than that in patients with cystic fibrosis without diabetes. Hypoglycemia, hyperglycemia, and glucose variability confer excess mortality and morbidity in the general inpatient population with diabetes. Methods: We investigated patterns of hypoglycemia and the association of hypoglycemia, hyperglycemia, and glucose variability with mortality and readmission rate in inpatients with CFRD. All capillary blood glucose (CBG) readings (measured using the Abbott Precision web system) of patients with insulin-treated CFRD measured within our health board between January 2009 and January 2015 were. Frequency and timing of hypoglycemia (<4 mmol/L) and was recorded. The effect of dysglycemia on readmission and mortality was investigated with survival analysis. Results: Sixty-six patients were included. A total of 22,711 CBG results were included in the initial analysis. Hypoglycemia was common with 1433 episodes (6.3%). Hypoglycemia ascertainment was highest between 2400 and 0600 h. Hypoglycemia was associated with a significantly higher rate of readmission or death over the 3.5-year follow-up period (P = 0.03). There was no significant association between hyperglycemia or glucose variability and the rate of readmission and mortality. Conclusion: Among inpatients with CFRD hypoglycemia is common and is associated with an increased composite endpoint of readmission and death. As with previously reported trends in general inpatient population this group shows a peak incidence of hypoglycemic during the night

Visit-to-visit HbA1c variability and systolic blood pressure (SBP) variability are significantly and additively associated with mortality in individuals with type 1 diabetes: an observational study

Aim: To investigate the relationship between variability in both visit‐to‐visit HbA1c and SBP and mortality in individuals with type 1 diabetes. Methods: The Scottish Care Information (SCI) Diabetes dataset was used to identify 5952 individuals with type 1 diabetes for inclusion in this observational study. The SCI‐Diabetes dataset allowed access to blood pressure values, HbA1c readings, demographic information and mortality rates for all study participants. Participants were dichotomized to above and below median values for both HbA1c coefficient of variation (CV) and SBP CV, thus dividing participants into 4 cohorts for survival analysis. Survival analysis was carried out over 1430 days. A Cox proportional hazard model was used to allow comparison of mortality between the 4 cohorts. Results: Of the 5952 patients, death occurred in 416. CV for both HbA1c and SBP were significantly associated with mortality. The median values for HbA1c CV and SBP CV were 8.0 and 8.1, respectively. The hazard ratio for high HbA1c CV only (P = .0015) was 1.78 ± 0.36. The hazard ratio for high SBP CV only (P = .0018) was 1.69 ± 0.33. The hazard ratio for both high HbA1c CV and high SBP CV (P < .00001) was 2.37 ± 0.32. Conclusions: Our findings demonstrate that variability of both HbA1c and SBP is significantly and additively associated with mortality in individuals with type 1 diabetes. The variability of these parameters might be useful for risk stratification and is a potential target for future interventional studies

Capillary blood glucose monitoring, inpatient hypoglycaemia and quality of care

Aims: Hypoglycaemia confers excess morbidity and mortality. UK guidelines recommend capillary blood glucose (CBG) measurement is repeated 15 minutes following identification and treatment of CBG <4mmol/l. We assessed adherence to this guidance, influence of initial CBG on time to repeat (TTR), and the impact of a quality improvement intervention on TTR. Methods: We identified CBG readings (Abbott-PrecisionWeb) of 18,118 inpatients with recorded hypoglycaemic CBG between January 2009 and September 2013. TTR and associations with initial CBG were investigated. A single ward was targeted with an intervention (National Health Service Scotland Quality Improvement Hub ThinkGlucose pilot) during 2012. TTR was identified and compared before, during and after intervention. Results: Of 90,935 CBGs <4mmol/l, 4.4% had no recorded repeat CBG. Of the 83,484 repeated CBGs, median TTR was 80 minutes, with 8.9% repeated within 15 minutes and only 42.2% within 60 minutes. TTR was proportional to initial CBG with median 22 minutes (IQR 10-47) for initial CBG 1-1.9 mmol/l, median 48 minutes (IQR 24-104) for 2-2.9 mmol/l, median 112 minutes (IQR 52-309) for 3-3.9 mmol/l(p=0.05). On the vascular unit, TTR improved post intervention from a median 77 minutes (IQR 37-281, n=843) to 29 minutes (IQR 19-55, n = 1041), and improvement persisted with median 20 minutes (IQR 15-28, n=268) in the nine months after the project ended. Conclusions: TTR is a marker of treatment quality in hypoglycaemia and is suboptimal. TTR reduces with worsening initial degree of hypoglycaemia. We have shown a quality improvement package can produce sustained reduction of TTR

Capillary blood glucose monitoring, inpatient hypoglycaemia and quality of care

Aims: Hypoglycaemia confers excess morbidity and mortality. UK guidelines recommend capillary blood glucose (CBG) measurement is repeated 15 minutes following identification and treatment of CBG <4mmol/l. We assessed adherence to this guidance, influence of initial CBG on time to repeat (TTR), and the impact of a quality improvement intervention on TTR. Methods: We identified CBG readings (Abbott-PrecisionWeb) of 18,118 inpatients with recorded hypoglycaemic CBG between January 2009 and September 2013. TTR and associations with initial CBG were investigated. A single ward was targeted with an intervention (National Health Service Scotland Quality Improvement Hub ThinkGlucose pilot) during 2012. TTR was identified and compared before, during and after intervention. Results: Of 90,935 CBGs <4mmol/l, 4.4% had no recorded repeat CBG. Of the 83,484 repeated CBGs, median TTR was 80 minutes, with 8.9% repeated within 15 minutes and only 42.2% within 60 minutes. TTR was proportional to initial CBG with median 22 minutes (IQR 10-47) for initial CBG 1-1.9 mmol/l, median 48 minutes (IQR 24-104) for 2-2.9 mmol/l, median 112 minutes (IQR 52-309) for 3-3.9 mmol/l(p=0.05). On the vascular unit, TTR improved post intervention from a median 77 minutes (IQR 37-281, n=843) to 29 minutes (IQR 19-55, n = 1041), and improvement persisted with median 20 minutes (IQR 15-28, n=268) in the nine months after the project ended. Conclusions: TTR is a marker of treatment quality in hypoglycaemia and is suboptimal. TTR reduces with worsening initial degree of hypoglycaemia. We have shown a quality improvement package can produce sustained reduction of TTR