Virtual glucose monitoring service may improve inpatient glycemic control

The service used the electronic health record to send daily reports on inpatients with abnormal glucose values or insulin pump use to experienced diabetes clinicians who could remotely enter a glucose management note with insulin recommendations.

A virtual glucose management service decreased the number of inpatients who developed hyperglycemia or hypoglycemia in a recent study.

The virtual service entailed the electronic health record generating daily reports that identified all adult inpatients with abnormal glucose values or insulin pump use. Then, before early morning rounds, one of three experienced diabetes clinicians reviewed each patient's chart and, if necessary, remotely entered a glucose management note with insulin recommendations.

To evaluate the effects of the service, researchers analyzed three 12-month periods between June 1, 2012, and May 31, 2015, (pre-intervention, transition, and intervention) at three University of California, San Francisco hospitals. They included 12,535 nonobstetric adult inpatients who underwent point-of-care glucose testing in the study. Results of the observational study were published online on March 28 by Annals of Internal Medicine.

Primary outcomes were the proportion of patient-days classified as hyperglycemic (two or more glucose values ≥12.5 mmol/L [225 mg/dL]), at-goal (all glucose values between 3.9 and 10 mmol/L [70 and 180 mg/dL]), or hypoglycemic (a single glucose value <3.9 mmol/L [70 mg/dL] or <2.2 mmol/L [40 mg/dL] for severe hypoglycemia) per 100 hospitalized patients on a given calendar day.

From the pre-intervention period to the intervention period, the proportion of hyperglycemic patients per day decreased by 39%, from 6.6 per 100 patients to 4.0 per 100 patients (P<0.001). Meanwhile, the proportion of at-goal patient-days increased by 5%, from 10.8 per 100 patients in the pre-intervention period to 11.4 per 100 patients during the intervention period (P<0.001). During the same period, the proportion of hypoglycemic patients per day decreased by 36%, from 0.78 per 100 patients to 0.49 per 100 patients (P<0.001). In addition, the proportion with severe hypoglycemia decreased by 69%, from 0.032 per 100 patients to 0.010 per 100 patients (P<0.001).

One limitation of the study is that researchers did not collect information on patients' concurrent illnesses and treatments that might influence outcomes or information on physicians' orders, the authors noted.

An accompanying editorial called the improvements in glycemic control “impressive” but expressed concerns about adoption in inpatient settings outside the U.S. where there has been slower uptake of EHRs and electronic prescribing.

Another downside of the service is the absence of patient and subspecialist interaction, according to the editorial. “It is important to note that the 3 providers who gave advice had 10 to 30 years of inpatient diabetes experience among them,” the editorialist wrote. “Even greater improvements may have been possible if this level of experience were available at bedside.”