Management of raised glucose, a clinical decision tool to reduce length of stay of patients with hyperglycaemia

Can Clinical Outcomes Be Improved, and Inpatient Length of Stay Reduced for Adults With Diabetes? A Systematic Review

AIM

To examine the efficacy of clinical practice strategies in improving clinical outcomes and reducing length of hospital stay for inpatients with Type 1 and Type 2 diabetes.

BACKGROUND

People living with diabetes are at increased risk of being admitted to hospital and to stay in hospital longer than those who do not have the condition. Diabetes and its complications cause substantial economic loss to those living with the condition, their families, to health systems and national economies through direct medical costs and loss of work and wages. Length of stay is a major factor driving up hospitalisation costs relating to those with Type 1 and Type 2 diabetes with suboptimal blood glucose management, hypoglycaemia, hyperglycaemia, and co-morbidities shown to considerably impact upon length of stay. The identification of attainable evidence-based clinical practice strategies is necessary to inform the knowledge base and identify service improvement opportunities that could lead to improved clinical outcomes for these patients.

STUDY DESIGN

A systematic review and narrative synthesis.

METHODS

A systematic search of CINAHL, Medline Ovid, and Web of Science databases was carried out to identify research papers reporting on interventions that have reduced length of hospital stay for inpatients living with diabetes for the period 2010-2021. Selected papers were reviewed, and relevant data extracted by three authors. Eighteen empirical studies were included.

RESULTS

Eighteen studies spanned the themes of clinical management innovations, clinical education programmes, multidisciplinary collaborative care and technology facilitated monitoring. The studies demonstrated improvements in healthcare outcomes such as glycaemic control, greater confidence with insulin administration and reduced occurrences of hypoglycaemia and hyperglycaemia and decreased length of hospital stay and healthcare costs.

CONCLUSIONS

The clinical practice strategies identified in this review contribute to the evidence base for inpatient care and treatment outcomes. The implementation of evidence-based research can improve clinical practice and show that appropriate management can enhance clinical outcomes for the inpatient with diabetes, potentially leading to reductions in length of stay. Investment in and commissioning of practices that have the potential to afford clinical benefits and reduce length of hospital stay could influence the future of diabetes care.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=204825, identifier 204825.

Factors influencing hospital conveyance following ambulance attendance for people with diabetes: A retrospective observational study

AIM

To assess variables contributing to hospital conveyance for people with diabetes and the interactions between them. A secondary aim was to generate hypotheses for further research into interventions that might reduce avoidable hospital admissions.

METHODS

A national retrospective data set including 30 999 diabetes-related callouts from the Scottish Ambulance Service was utilized covering a 5-year period between 2013 and 2017. The relationship between diabetes-related hospital conveyance and seven potential risk factors was analysed. Independent variables included: age, gender, deprivation, paramedic attendance, treatment at the scene, first blood glucose measurement and day of the week.

RESULTS

In Scotland, hyperglycaemia was associated with a higher number of people being conveyed to hospital than hypoglycaemia (49.8% with high blood glucose vs. 39.3% with low glucose, P ≤ 0.0001). Treatment provided in pre-hospital care was associated with reduced conveyance rates (47.3% vs. 58.2% where treatment was not administered, P ≤ 0.0001). Paramedic attendance was also associated with reduced conveyance to hospital (51.4% vs. 59.5% where paramedic was not present, P ≤ 0.0001). Paramedic attendance in hyperglycaemic cases was associated with significantly reduced odds of conveyance (odds ratio 0.52, P ≤ 0.001).

CONCLUSIONS

A higher rate of conveyance associated with hyperglycaemic cases indicates a need for more resources, education and training in this area. Higher conveyance rates were also associated with no paramedic being present and no treatment being administered. This suggests that paramedic attendance may be crucial in reducing avoidable admissions. Developing and validating protocols for pre-hospital services and treatment may help to reduce hospital conveyance rates.

Cost and economic benefit of clinical decision support systems for cardiovascular disease prevention: a community guide systematic review

Objective

This review evaluates costs and benefits associated with acquiring, implementing, and operating clinical decision support systems (CDSSs) to prevent cardiovascular disease (CVD).

Materials and Methods

Methods developed for the Community Guide were used to review CDSS literature covering the period from January 1976 to October 2015. Twenty-one studies were identified for inclusion.

Results

It was difficult to draw a meaningful estimate for the cost of acquiring and operating CDSSs to prevent CVD from the available studies ( n  = 12) due to considerable heterogeneity. Several studies ( n  = 11) indicated that health care costs were averted by using CDSSs but many were partial assessments that did not consider all components of health care. Four cost-benefit studies reached conflicting conclusions about the net benefit of CDSSs based on incomplete assessments of costs and benefits. Three cost-utility studies indicated inconsistent conclusions regarding cost-effectiveness based on a conservative $50,000 threshold.

Discussion

Intervention costs were not negligible, but specific estimates were not derived because of the heterogeneity of implementation and reporting metrics. Expected economic benefits from averted health care cost could not be determined with confidence because many studies did not fully account for all components of health care.

Conclusion

We were unable to conclude whether CDSSs for CVD prevention is either cost-beneficial or cost-effective. Several evidence gaps are identified, most prominently a lack of information about major drivers of cost and benefit, a lack of standard metrics for the cost of CDSSs, and not allowing for useful life of a CDSS that generally extends beyond one accounting period.