Diabetes care in hospitalized noncritically ill patients: More evidence for clinical inertia and negative therapeutic momentum

BACKGROUND: Little is known about management of hyperglycemia in inpatient. OBJECTIVE: To gain insight into caring for hospitalized patients with hyperglycemia. DESIGN: Retrospective analysis. SETTING: Teaching hospital. PATIENTS: Data on all patients discharged between January 1, 2001, and December 31, 2004 with a diagnosis of diabetes or hyperglycernia were extracted and linked to laboratory and pharmacy databases. Only the data on patients who did not require intensive care and who were hospitalized for at least 3 days were analyzed. MEASUREMENTS: Average bedside glucose during the first and last 24 hours of hospital stay and for the entire length of stay; assessment of changes in insulin regimen and dose. RESULTS: The average age of patients included in the study (n = 2916) was 69 years. Fifty-seven percent of the patients were men, 90% were white, and average length of stay was 5.7 days. More than 20% of the patients had evidence of sustained hyperglycernia. Forty-two percent of the patients who showed poor control of glycemia (glucose > 200 mg/dL during the first 24 hours were discharged in poor control. The frequency of hypoglycemia was low (only 2.2 of 100 measurements per person) compared with hyperglycernia (25.5 of 100 measurements per person). Most patients (72%) received insulin during hospitalization, but there was high use of short-acting insulin and less than optimal intensification of therapy (clinical inertia); many patients had insulin therapy decreased despite persistent hyperglycernia (negative therapeutic momentum). CONCLUSIONS: Glycemic control in the hospital was frequently poor, and there was suboptimal use of insulin, even among patients with sustained hyperglycernia. Educational programs directed at practitioners should focus on the importance of inpatient glucose control and provide guidelines on how and when to change therapy.