Pharmacist-Led Teams Improve Postsurgical Glycemic Control

Miriam E Tucker

November 02, 2015

In-hospital pharmacist-led perioperative management teams can help improve glycemic control and reduce postoperative healthcare costs in patients with diabetes or stress-related hyperglycemia who are undergoing surgery, a new study suggests.

The findings were published online October 27 in the American Journal of Pharmacy Benefits by David M Mosen, PhD, senior program evaluation consultant at Kaiser Permanente Center for Health Research, Portland, Oregon, and colleagues.

In the intervention, pharmacists provided insulin dosing, ordered blood glucose monitoring and relevant laboratory testing, requested consults with dietitians and diabetes educators, and made recommendations for postdischarge regimens for insulin, oral medications, and diabetes supplies.

"By resourcing a glycemic-control pharmacist program, we can not only improve blood sugar control and reduce hypoglycemia — key safety measures in themselves — but apparently prevent later complications that could lead to return visits to the emergency department or readmission to the hospital.…We expected the improvement in blood sugar control but were surprised by the other findings," Dr Mosen told Medscape Medical News.

Pharmacist-Run Protocol

The study population included 11,553 unique non–critically ill surgical inpatients admitted to the postanesthesia care unit at a tertiary-care multispecialty center.

Included were patients with preexisting diabetes, newly diagnosed diabetes, and stress-induced hyperglycemia. Recent data suggest that 30% to 50% of inpatients in the United States have diabetes and/or stress-related hyperglycemia, the authors note.

Patient-level outcomes were assessed during a 12-month preintervention period and compared at years 1 and 2 postintervention. Of the total group, 1277 were seen in the preintervention period, 4811 in year 1 postintervention, and 5465 in year 2.

The protocol was created by a pharmacy clinical coordinator who worked closely with physicians experienced in diabetes management from the endocrinology, hospitalist, and surgery departments.

Components of the program included recommendations for when to begin and discontinue IV insulin, transitioning from IV therapy, calculating injected insulin doses, adjusting insulin doses, resumption of oral agents, management of tube-fed patients, and discharge planning.

Under the protocol, the pharmacist is allowed to provide inpatient glycemic management, including writing and adjusting daily insulin orders as well as ordering labs, placing consultation requests for registered dieticians and/or diabetes educators, and — in collaboration with clinicians — placing discharge orders for insulin and diabetes supplies.

The pharmacist also interacts with patients to discuss their treatment plan, identifies barriers to good outpatient control, and communicates the discharge plan.

Program Results in Better Control, Fewer Readmissions, and Lower Costs

After adjustment for covariates — including age, gender, race/ethnicity, poverty status, Charlson comorbidity index, surgery type, prior hospital utilization, and preoperative glycemic control, patients were more likely to have good glycemic control in year 1 (odds ratio [OR], 2.24; P < .001) and year 2 (OR, 2.19; P < .0001) after the intervention was implemented, compared with the preintervention period.

And patients were less likely to have hypoglycemia in year 1 (OR, 0.38; P < .0001) and year 2 (OR, 0.31; P < .0001) postintervention, compared with the preintervention period, even after adjustment for covariates.

Significant reductions were also seen in wound-infection–related readmissions in year 2 compared with preintervention (OR, 0.51; P = .031), in all-cause hospital readmissions in year 1 (OR, 0.69, P = .03) and year 2 (OR, 0.67; P = .008), and in all-cause postdischarge emergency-department utilization in both years (OR, 0.71; P = .003 and OR, 0.72; P = .009, respectively), after covariate adjustment.

And postdischarge per-patient per-month medical costs were lower in both year 1 (P < .0001) and year 2 (P = .010) compared with preintervention and after adjustment for the covariates.

"A hospitalization for any reason, including surgery, is complex. Many care decisions and providers must interact to provide the myriad of interventions necessary to treat the patient," Dr Mosen told Medscape Medical News.

"By providing a structured and reliable system of care, employing dedicated pharmacists to implement guideline-recommended glycemic-control care, we were able to ensure focused and comprehensive attention to glycemic control without competing priorities," he added.

Prior to use of the pharmacist team, diabetes/glucose management was left to the discretion of the attending surgeon to write orders or formally consult another physician with expertise in inpatient diabetes management — typically a hospitalist, Dr Mosen explained.

The pharmacist program is of great help to physicians, he noted.

"Having a trained inpatient glycemic-control pharmacist available to immediately provide consultation and institute and adjust treatment for any patient with known diabetes and/or elevated blood glucose, all day, 7 days a week, allowed surgeons and anesthesia providers to focus on the specialized surgical aspects of care."

The authors have no relevant financial relationships.

Am J Pharm Benefits. Published online October 27, 2015. Article


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