Hospitalized T2DM Patients: A Missed Opportunity?

Richard M. Plotzker, MD


November 19, 2015

Benign -- or Not so Benign -- Neglect?

Pardon me while I climb up on my soapbox...

Recently, I've been asked to consult on some diabetic patients who were neither new nor deteriorating, though their disease was never were quite controlled after two or more hospital encounters that apparently failed to address their glycemic issues. After meticulous chart reading—something that many mavens of my generation do—I encountered a long series of primary lab data and discharge summaries, the latter of which would have been provided to the primary physicians inheriting those patients after discharge.

One summary in particular caught my attention. The word "diabetes" had been dictated by one of the house staff, although it did not appear anywhere else in the text of the report except as a secondary diagnosis. There is an addendum on that summary from one of the hospitalists who received a call from the visiting nurse the following day, asking for instructions on diabetic management that were not included with the discharge and appear nowhere in that summary's course of hospitalization. On other summaries, diabetes is similarly not mentioned in the hospital course at all, with the only reference being a glucose number well above normal.

Judging from the unchanged hyperglycemia and a list of drugs and doses that were the same on admission and discharge, it would be safe to conclude that updating the diabetes regimen was not one of the prime goals of hospitalization.

True, most individuals with diabetes who are admitted to the hospital are there for reasons other than hyperglycemia. But double-digit A1c values and glucose levels above 200 mg/dL are hardly subtle hints that perhaps some revision in medical care might be in order—even if it's just sending a "heads-up" to the primary care physician. Unfortunately, in my cases, this managed to stay under the radar even with repeated hospitalizations.

In this era when incentives push us to process patients through their acute illness in as few nights as possible, even interdisciplinary meetings among physicians, head nurses, discharge planners, dietitians, and social workers—all discussing the same patient at the same time—too often fail to cover what to do about some pretty glaring lab values.

Finding the Right Balance

About 15 years ago, while I was in private practice, I was asked to serve on a committee to develop statewide standards for diabetic care among hospital patients. The committee included diabetologists, diabetes educators, nurse practitioners, nursing supervisors, a dietitian, and a few people who wore suits to work. The resulting document was the antithesis of the diabetic neglect I described above. The state proposed requiring that all diabetics have a comprehensive history of their diabetes, including a full summary of all previous treatments, extensive lab testing, and consults by people who would contribute little but run up a big tab, with no selectivity whatever as to why the patient was in the hospital.

I suppose if you see only diabetes all day long, your perspective is one of diabetes. That's the difference between having knowledge and having understanding. Hypercorrecting is really just a variant of being wrong. You cannot clutter the chart of every person having hip surgery, or with terminal cancer or chronic obstructive pulmonary disease, with medical analysis and testing that is not immediately purposeful, just for the sake of completeness. But neither can you let opportunities to better manage a devastating chronic illness just slip by.

What you can do, and what I think we should do, is refine medical care and think about the patient in the hospital and in transition to the next destination. Some lab data just stare at you as a red flag. So do histories provided by patients who only get episodic care, often during a hospital encounter. As much as checklists often seem troublesome, this might be one time for house staff and hospitalists who supervise them to create a "to-do" list of things to be acted upon in the moment of opportunity.

I also think there needs to be a better interface between hospital care and office care, something which has atrophied terribly in recent years. Hospital-based clinicians who have not worked in the office setting may not realize that starting insulin in the hospital is a lot easier than starting insulin in the office, for instance. Although it may not be realistic to bring glucose levels completely under control during a 2- or 3-day hospitalization, planning what it takes to control it over the next 2-3 months, as well as sorting out the sequelae that the next physician will need to address, should be within the goals of most hospitalizations.

That way, the next time these people find their way into the hospital for altered mental status, or a urinary tract infection, or whatever else lands them in the emergency department, glycemic control and its related troubleshooting will already have been undertaken.

Descending from my soapbox...


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