Endocrine Hospitalist-Led Service Improves Diabetes Care

Miriam E. Tucker

July 10, 2020

Dr Mihail Zilbermint

Mihail ("Misha") Zilbermint, MD, is an unusual medical provider in an atypical practice setting: he's a full-time endocrine hospitalist who heads an inpatient diabetes management service at a small community hospital. But if early evidence of his success continues, such models could be increasingly adopted.

Zilbermint's official title is chief and director of endocrinology, diabetes, and metabolism at Johns Hopkins Community Physicians at Suburban Hospital in Bethesda, Maryland. Last month, he described the program during a talk at the virtual American Diabetes Association (ADA) 80th Scientific Sessions entitled, “Can an inpatient diabetes management service decrease length of stay and prevent readmission?”

Later, he shared more details with Medscape Medical News about the service, what has been accomplished so far since the program's launch in late 2015, and how it has been called into duty during the COVID-19 pandemic.

Medscape: How did you become an endocrine hospitalist, and how did Suburban's Inpatient Diabetes Management Service get started?

Zilbermint: I did my endocrinology fellowship at the National Institutes of Health in Bethesda, Maryland. While I was there, in 2013, I began moonlighting for extra money for the hospitalist team at the nearby Suburban Hospital, a 228-bed community hospital that became a member of the Johns Hopkins Health System in 2009.

Staff members who knew I was training in endocrinology started asking me for help with their patients who had diabetes. About a quarter of all the inpatients at Suburban had diabetes, yet I noticed that the diabetes care they were receiving wasn't what I would have expected from a Johns Hopkins-affiliated hospital. Patients were having a lot of hyper- and hypoglycemic episodes. I was often able to help on a case-by-case basis.

I really liked Suburban's hospitalist team and considered working there full-time once my fellowship ended in 2015. I met with the team's leaders in August 2014 and offered to work there as a hospitalist as long as I could do some endocrine work as well. As it turned out, there were enough patients with diabetes and other endocrine disorders to support hiring a full-time endocrine hospitalist.

I knew that I would need to work within an evidence-driven inpatient diabetes management program, similar to those that already existed in some larger teaching hospitals, including the flagship Johns Hopkins Hospital in Baltimore. The part I wasn't really prepared for was putting together a business plan.

Medscape: How did that plan come together and what were some of the initial challenges? 

Zilbermint: The first challenge was convincing hospital administration to view an inpatient diabetes management service as an asset rather than an expense. The cost of establishing an inpatient management program would need to bring a return on investment.

We know that the cost of diabetes is huge, more than $200 billion [in the United States] in 2017. And we also know, from numerous studies, that dysglycemia during hospitalization is associated with increased length of stay and higher 30-day readmission rates. In one notable study of patients undergoing coronary artery bypass surgery, each 50 mg/dL increase in glucose prolonged hospital stay by 0.76 additional post-operative days and raised hospital charges by nearly $3,000.  

And various aspects of an inpatient diabetes management service, including education, have been shown to reduce length of stay and/or readmission rates, resulting in cost savings.  

In 2012, the US Centers for Medicare and Medicaid Services (CMS), in collaboration with a number of US states, incentivized hospitals to reduce avoidable readmissions by linking those rates to rewards and penalties. And in 2014, the state of Maryland launched its own readmission reduction project as part of a national value-based care pilot with CMS.

Since I had no background in business, I reached out to several individuals who did. I also enlisted the support of the hospital vice president for medical affairs and the chief medical officer, the hospital chief executive officer, Johns Hopkins Community Physicians, and the Johns Hopkins School of Medicine.

Fortunately, I had a great model to work from: the multifaceted inpatient diabetes management program at the flagship Johns Hopkins Hospital had been established in 2006, under the leadership of Sherita H. Golden, MD, and Nestoras Mathioudakis, MD. 

As they had done, we collected data for key metrics at Suburban including current length of stay and 30-day readmission rates, and the incidence of glucose-related safety events and mortality. We established goals and metrics to define success, and attempted to quantify the financial impact of not meeting those goals. 

We outlined the components of our program and estimated the number of full-time equivalents and relative value units we would need. This is important because you won't be able to show outcomes data for at least the first couple of years, and because we're still working in a fee-for-service system, it's important to at least make sure that there will be enough patients to offset the staff salaries and cover expenses upfront.

I'm now working on obtaining a masters in business administration (MBA) degree from Hopkins, which is giving me insights to improve that aspect of the program going forward.

Zilbermint and his inpatient team. Courtesy of Mihail Zilbermint.

 

Medscape: What are the key elements of Suburban's inpatient diabetes management service? 

Zilbermint: I lead the program at Suburban as a full-time endocrinologist. My role includes implementation of hyper- and hypoglycemia protocols and uniform insulin order sets. I also provide "lunch and learn" sessions to both physicians and nurses.

After about 6 months, I brought on two part-time endocrinologists as the patient volume increased, and the service expanded from 5 to 6 days per week. We then added a diabetes educator in 2017 and a full-time nurse practitioner in 2018.

Other elements of the program include a multidisciplinary glucose steering committee to address various aspects of glucose management, and a "diabetes nurse champions" committee that incorporates at least one nurse from each of the hospital units in a "train-the-trainer" approach.

We also developed a formal evidence-based hypoglycemia protocol and treatment algorithm, and hospital-wide education, in addition to adopting a clinical decision support tool, and a uniform subcutaneous insulin order set. And we connected into the glucometrics dashboard that had already been established at other Johns Hopkins facilities.

And importantly, because patients often fall through the cracks at the time of discharge, we work very hard to refer patients back to their primary medical doctor, an outpatient endocrinologist if appropriate or a safety net clinic, and diabetes classes. 

In May 2016 Suburban's Community Health and Wellness Department launched a "Fine Tune Your Diabetes" educational program for patients to attend after discharge, to reinforce self-management behaviors aimed at maintaining health and preventing readmissions.

Of course, not every patient with diabetes requires our services. We distributed guidelines for all staff to request consultation for the following: patients with glucose levels above 250 mg/dL or below 70 mg/dL, those on high-dose glucocorticoid therapy, those with type 1 diabetes, newly diagnosed type 2 diabetes, or admitted in diabetic ketoacidosis.

Medscape: What outcomes have you seen so far?

Zilbermint: Our retrospective quality improvement cohort study of 4654 inpatients with diabetes seen during January 2016 and May 2017 was published last year. Our service comanaged 18.3% of them. They had a mean age of 72 years, just over half were white (53.7%), and most had type 2 diabetes (94.7%). The comparison group of patients with diabetes received standard care, mostly from internal medicine-trained hospitalists.

As expected, our patients had longer lengths of stay and higher readmission rates since they were more complex to start with. However, mean length of stay in the patients we comanaged decreased by 27% (P < .0001) from baseline (from 7.8 days to 5.7 days), while there was no significant decline in the comparison group. Similarly, mean 30-day readmission rates decreased by 10.7% in our patients (from 25% to 14.3%; P = .048) while not changing in the comparison group.

Based on the length of stay decrease over time, we calculated that our service produced estimated costs of care savings of $953,578 over the study period.

We're now looking specifically at our cost savings from the hypoglycemia reduction element, and also from implementation of insulin pens instead of vials and syringes. And we're about to publish a review paper on the effect of inpatient diabetes management programs on outcomes and costs. 

Medscape: How has COVID-19 affected the program? 

Zilbermint: When we first started seeing COVID-19 patients in March, we implemented an inpatient telemedicine program to minimize the need for personal protective equipment. The nurse would leave an iPad in the patient's room and I would see them virtually from my office using Zoom.

It worked well until we became really inundated. At one point about 75% of all patients with diabetes on our service also had COVID-19. We didn't have time for all the Zoom visits so we reverted to seeing them as usual, or if they were able to talk, speaking with them on hospital phones, cell phones, or via the Doximity app. We have been helping the intensivists titrate the insulin. Unfortunately, some of the sickest patients with diabetes and COVID-19 do not do well.

Like most hospitals and hospital-based programs right now, we're doing our best to prepare for another COVID-19 surge. We hope that we can take what we've learned so far, leverage inpatient telemedicine, and give our patients with diabetes the best chance possible.

Zilbermint is a consultant for Guidepoint.

ADA 2020 Scientific Sessions. Presented on June 13, 2020.

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