1
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Koehn DA, Dungan KM, Wallia A, Lucas DO, Lash RW, Becker MN, Dardick LD, Boord JB. Reducing hypoglycemia from overtreatment of type 2 diabetes in older adults: The HypoPrevent study. J Am Geriatr Soc 2023; 71:3701-3710. [PMID: 37736005 DOI: 10.1111/jgs.18566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Hypoglycemia from overtreatment is a serious but underrecognized complication among older adults with type 2 diabetes. However, diabetes treatment is seldom deintensified. We assessed the effectiveness of a Clinical Decision Support (CDS) tool and shared decision-making (SDM) in decreasing the number of patients at risk for hypoglycemia and reducing the impact of non-severe hypoglycemic events. METHODS HypoPrevent was a pre-post, single arm study at a five-site primary care practice. We identified at-risk patients (≥65 years-old, with type 2 diabetes, treated with insulin or sulfonylureas, and HbA1c < 7.0%). During three clinic visits over 6 months, clinicians used the CDS tool and SDM to assess hypoglycemic risk, set individualized HbA1c goals, and adjust use of hypoglycemic agents. We assessed the number of patients setting individualized HbA1c goals or modifying medication use, changes in the population at risk for hypoglycemia, and changes in impact of non-severe hypoglycemic events using a validated patient-reported outcome tool (TRIM-HYPO). RESULTS We enrolled 94 patients (mean age-74; mean HbA1c (±SD)-6.36% ± 0.43), of whom 94% set an individualized HbA1c goal at either the baseline or first follow-up visit. Ninety patients completed the study. Insulin or sulfonylurea use was decreased or eliminated in 20%. An HbA1c level before and after goal setting was obtained in 53% (N = 50). Among these patients, the mean HbA1c increased 0.53% (p < 0.0001) and the number of patients at-risk decreased by 46% (p < 0.0001). Statistically significant reductions in the impact of hypoglycemia during daily activities occurred in both the total score and each functional domain of TRIM-HYPO. CONCLUSIONS In a population of older patients at risk for hypoglycemia, the use of a CDS tool and SDM reduced the population at risk and decreased the use of insulin and sulfonylureas. Using a patient-reported outcome tool, we demonstrated significant reductions in the impact of hypoglycemia on daily life.
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Affiliation(s)
| | - Kathleen Marie Dungan
- Division of Endocrinology, Diabetes & Metabolism, The Ohio State University, Columbus, Ohio, USA
| | - Amisha Wallia
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | | | | | - Jeffrey B Boord
- Department of Administration and Parkview Physicians Group Endocrinology Section, Parkview Health System, Fort Wayne, Indiana, USA
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2
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Newman CB, Blaha MJ, Boord JB, Cariou B, Chait A, Fein HG, Ginsberg HN, Goldberg IJ, Murad MH, Subramanian S, Tannock LR. Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2020; 105:5909161. [PMID: 32951056 DOI: 10.1210/clinem/dgaa674] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This guideline will provide the practicing endocrinologist with an approach to the assessment and treatment of dyslipidemia in patients with endocrine diseases, with the objective of preventing cardiovascular (CV) events and triglyceride-induced pancreatitis. The guideline reviews data on dyslipidemia and atherosclerotic cardiovascular disease (ASCVD) risk in patients with endocrine disorders and discusses the evidence for the correction of dyslipidemia by treatment of the endocrine disease. The guideline also addresses whether treatment of the endocrine disease reduces ASCVD risk. CONCLUSION This guideline focuses on lipid and lipoprotein abnormalities associated with endocrine diseases, including diabetes mellitus, and whether treatment of the endocrine disorder improves not only the lipid abnormalities, but also CV outcomes. Based on the available evidence, recommendations are made for the assessment and management of dyslipidemia in patients with endocrine diseases.
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Affiliation(s)
- Connie B Newman
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, New York
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Jeffrey B Boord
- Department of Administration and Parkview Physicians Group Endocrinology Section, Parkview Health System, Fort Wayne, Indiana
| | - Bertrand Cariou
- Department of Endocrinology, L'institut du thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Nantes, France
| | - Alan Chait
- Department of Medicine, University of Washington, Seattle, Washington
| | - Henry G Fein
- Department of Medicine, Division of Endocrinology, Sinai Hospital, Baltimore, Maryland
| | - Henry N Ginsberg
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ira J Goldberg
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, New York
| | - M Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
| | | | - Lisa R Tannock
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
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3
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Mukherjee K, Sowards KJ, Brooks SE, Norris PR, Boord JB, May AK. Insulin resistance increases before ventilator-associated pneumonia in euglycemic trauma patients. Surg Infect (Larchmt) 2015; 15:713-20. [PMID: 25215464 DOI: 10.1089/sur.2013.164] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Hyperglycemia caused by stress-induced insulin resistance is associated with both infection and mortality in critically injured patients. The onset of infection may increase stress-induced insulin resistance, leading to hyperglycemia. Hyperglycemia has been shown to precede the diagnosis of ventilator-associated pneumonia (VAP) in critically injured adults and has been suggested to have potential diagnostic importance. However, glycemic control (GC) protocols in critically ill patients limit the development of hyperglycemia despite increasing insulin resistance. Our computer-assisted GC protocol achieves excellent GC, limiting infection-related hyperglycemia while capturing prospectively all glucose values, insulin infusion rates, and the multiplier (M) used to calculate the insulin rate. We hypothesized that surrogate measures of insulin resistance, the insulin infusion rate and multiplier M, would increase prior to the clinical suspicion of VAP, even in euglycemic critically injured patients. METHODS All critically injured patients (2,656) on the computerized glycemic control protocol were included in the analysis and categorized by those developing VAP and those without pneumonia on days 3-10 of their intensive care unit (ICU) stay. Median blood glucose concentration (BG), insulin infusion rate (IDR), and multiplier (M) [Insulin Drip Rate=M*(BG-60)] were determined for VAP patients (n=329) and non-infected ventilated (NIV) patients (n=2,327) on each day of mechanical ventilation. The day of VAP diagnosis according to U.S. Centers for Disease Control and Prevention (CDC) criteria was defined as day zero and VAP patients matched with NIV patients according to ventilator day from -10 to +10. Comparisons were conducted using the Mann-Whitney U test. RESULTS Baseline characteristics between VAP and NIV groups did not differ. Measures of insulin resistance increased from the time of injury in both groups. Patients with VAP had significantly greater change in both measures of insulin resistance, IDR and M, in the 48 hours preceding the diagnosis of VAP. These changes occurred despite the fact that the computer-assisted GC protocol achieved lower glucose values in VAP patients for the majority of study days. CONCLUSIONS Measures of insulin resistance increase in the two days prior to the clinical suspicion of VAP for critically injured patients on the GC protocol. These changes occur despite the protocol maintaining euglycemia. This data suggests that markers of insulin resistance may provide clinically useful information in the early diagnosis of VAP.
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Affiliation(s)
- Kaushik Mukherjee
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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4
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Mukherjee K, Sowards KJ, Brooks SE, Norris PR, Jenkins JM, Smith MA, Bonney PM, Boord JB, May AK. Insulin Resistance in Critically Injured Adults: Contribution of Pneumonia, Diabetes, Nutrition, and Acuity. Surg Infect (Larchmt) 2015; 16:490-7. [PMID: 26270204 DOI: 10.1089/sur.2014.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Changes in insulin resistance (IR) cause stress-induced hyperglycemia after trauma, but the numerous factors involved in IR have not been delineated clearly. We hypothesized that a statistical model could help determine the relative contribution of different clinical co-variates to IR in critically injured patients. PATIENTS AND METHODS We retrospectively studied 726 critically injured patients managed with a computer-assisted glycemic protocol at an academic level I trauma center (639 ventilated controls without pneumonia (VWP) and 87 patients with ventilator-associated pneumonia (VAP). Linear regression using age, gender, body mass index (BMI), diabetes mellitus, pneumonia, and glycemic provision was used to estimate M, a marker of IR that incorporates both the serum blood glucose concentration (BG) and insulin dose. RESULTS Increasing M (p<0.001) was associated with age (1.62%; 95% confidence interval [CI] 1.27%-1.97% per decade), male gender (9.78%; 95% CI 8.28%-12.6%), BMI (4.32% [95% CI 4.02%-4.62%] per 5 points), diabetes mellitus (21.2%; 95% CI 19.2%-23.2%), pneumonia (10.9%; 95% CI 9.31%-12.6%), and glycemic provision (27.3% [95% CI 6.6%-28.1%] per 100 g of glucose). Total parenteral nutrition was associated with a decrease in M of 10.3%; 95% CI 8.52%-12.1%; p<0.001. CONCLUSIONS Clinical factors can be used to construct a model of IR. Prospective validation might enable early detection and treatment of infection or other conditions associated with increased IR.
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Affiliation(s)
- Kaushik Mukherjee
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Kendell J Sowards
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Steven E Brooks
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Patrick R Norris
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Judith M Jenkins
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Miya A Smith
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Paul M Bonney
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Jeffrey B Boord
- 2 Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Addison K May
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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5
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Draznin B, Gilden J, Golden SH, Inzucchi SE, Baldwin D, Bode BW, Boord JB, Braithwaite SS, Cagliero E, Dungan KM, Falciglia M, Figaro MK, Hirsch IB, Klonoff D, Korytkowski MT, Kosiborod M, Lien LF, Magee MF, Masharani U, Maynard G, McDonnell ME, Moghissi ES, Rasouli N, Rubin DJ, Rushakoff RJ, Sadhu AR, Schwartz S, Seley JJ, Umpierrez GE, Vigersky RA, Low CC, Wexler DJ. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care 2013; 36:1807-14. [PMID: 23801791 PMCID: PMC3687296 DOI: 10.2337/dc12-2508] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.
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Affiliation(s)
- Boris Draznin
- Division of Endocrinology, Diabetes and Metabolism, University of Colorado School of Medicine, Aurora, Colorado, USA.
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6
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Abstract
OBJECTIVE We examined the effect of hospital admissions on the medical treatment of poorly controlled diabetes mellitus among Veterans Affairs (VA) patients. RESEARCH DESIGN AND METHODS This retrospective cohort study included male patients admitted to one of three VA hospitals from July 1, 2002, to August 31, 2009, who were receiving medication therapy for diabetes with hemoglobin A1c (HgbA1c) greater than 8.0%. The primary outcome was a change in preadmission and outpatient prescriptions for diabetes at hospital discharge. Covariates for multivariable logistic regression analysis of the primary outcome were defined a priori and retrieved from the electronic health record. RESULTS Of 2025 admissions for 1359 patients, 454 had some change in diabetes medications at discharge (rate of change 22.4%). In an adjusted analysis, higher preadmission HgbA1c [odds ratio (OR) 1.12 per 1.0 U increase; 95% confidence interval (CI) 1.12-1.05; P < 0.001], higher mean blood glucose during admission (OR 1.07 per 10 mg/dl increase; 95% CI 1.05-1.10; P < 0.0001), occurrence of inpatient hypoglycemia (blood glucose < 50 mg/dl; OR 1.82, 95% CI 1.32-2.51, P < 0.001), and inpatient basal insulin therapy (OR 1.71; 95% CI 1.25-2.35; P < 0.001) were associated with higher odds of change in therapy. A total of 656 admissions (32%) demonstrated aggregate clinical inertia with no change in therapy, no documentation of HgbA1c within 60 d of discharge, and no follow-up appointment within 30 d of discharge. CONCLUSIONS In this multicenter, retrospective study of patients with poorly controlled diabetes and at least one hospitalization, less than a quarter received a change in outpatient diabetes therapy upon discharge, suggesting widespread clinical inertia. Nearly one third had no change in therapy or subsequent follow-up scheduled.
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Affiliation(s)
- Michelle L Griffith
- Veterans Affairs Tennessee Valley Healthcare System, A-413 VA/GRECC, 1310 24th Avenue South, Nashville, Tennessee 37212, USA
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7
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Boord JB, Symlar R, Cunningham BL, McPherson J, Burns K, Byrd J. Abstract P294: Transport Time Out for Cardiovascular Intensive Care Unit Patients Traveling off of the Unit. Circ Cardiovasc Qual Outcomes 2011. [DOI: 10.1161/circoutcomes.4.suppl_1.ap294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Transportation of critically ill patients to other areas for diagnostic testing or procedures can present risks to patient safety. It is necessary to ensure that the same level of care and support be provided for critically ill patients when they are removed from the ICU environment. There were no established processes available in the literature to address this safety issue.
Aim:
To establish a “transport time out” checklist process for transport of critically ill patients outside of the ICU environment. This process ensures that patient care and monitoring continues at the level deemed necessary by patient condition without interruption.
Methods:
A multidisciplinary team of nurses, physicians, and respiratory therapists created an algorithm to ensure that crucial care elements were considered prior to leaving the ICU environment with a critically ill patient. Elements were categorized in the “Airway, Breathing, Circulation, Drugs (ABCD)” format. Tools developed included a flowchart and transport time out check list (Figure).
Results:
The checklist outlines essential equipment and supplies for respiratory care, intravenous infusions, and clinical monitoring. The process has been in use for over 9 months encompassing approximately 330 patient transports. The process was rapidly and widely accepted by nursing staff. No adverse events during transport have occurred since implementation of the transport time out process.
Conclusion:
Use of a “transport time out” checklist process potentially can decrease the likelihood of adverse events during transport of a critically ill patient from the ICU. The process was simple and easy to implement.
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8
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Boord JB, Byrd J, DiSalvo T, Cunningham BL. Abstract P295: Performance Management and Improvement: One Way to “ImPact” Outcomes. Circ Cardiovasc Qual Outcomes 2011. [DOI: 10.1161/circoutcomes.4.suppl_1.ap295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Continuous quality improvement (CQI) in health care systems necessitates an approach to review care delivery processes, systems, group and individual performances, incidents and outcomes. A robust process should 1) be multidisciplinary, 2) occur in “real-time”, 3) provide detailed review and discussion of care processes, performance and outcomes and 4) generate actionable rapid cycle improvement opportunities.
Aim:
To craft a sustainable management process for CQI for all clinical operational units of the Vanderbilt Heart and Vascular Institute (VHVI).
Methods:
We convened a standing multidisciplinary biweekly managerial forum (termed ImPact - “Improving Patient Care Together”) of quality medical directors, key clinical physicians and nurses, nursing unit managers, hospital administrators, and quality consultants. ImPact follows a standing structured agenda: 1) all mortalities since last meeting, 2) morbidity including “major misses” and major adverse events, 3) rapid response team calls, 4) out of ICU “codes”, 5) events reported by staff in our hospital's anonymous reporting system, 6) events brought forward by any clinician or unit manager, 7) interval progress on ongoing rapid cycle improvement projects.
Results:
The topics for rapid cycle improvement that have surfaced to date are listed in the
Table
. In addition to facilitating and prioritizing rapid cycle quality improvement and patient safety efforts, ImPact provides a link to our regular morbidity and mortality (M&M) conferences in cardiology and cardiac surgery. We have been able to identify common issues that extend beyond individual clinical care areas, allowing better understanding of vulnerabilities in systems of care
Conclusions:
A multidisciplinary, structured, regularly scheduled meeting of physician and nursing clinical and quality leaders, unit managers and administrators is a critical component of performance management and improvement.
Quality Topics Identified
Topics
Contribution, n
Percent
Handoff and communication
9
27
Equipment
7
21
Medication administration
5
15
Education to staff (M&M)
4
12
Patient transport
3
9
Blood product administration
2
6
Risk management
2
6
Vascular service integration
1
3
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9
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Boord JB, Leutgens WS, Churchwell KB. Abstract P97: Operational Redesign of an Outpatient Anticoagulation Management Program- The Vanderbilt Experience. Circ Cardiovasc Qual Outcomes 2011. [DOI: 10.1161/circoutcomes.4.suppl_1.ap97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 2008 Joint Commission National Patient Safety Goals required healthcare organizations to adopt practices to reduce the likelihood of harm associated with use of anticoagulation therapy. Assessment of our anticoagulation programs in 2008 demonstrated gaps that did not meet these new requirements. Patients were enrolled in two large anticoagulation clinics (separately managed by pharmacy and cardiology) with smaller programs linked to their clinical service lines. Identified gaps included: separate programs that were not standardized and had no integrated governance/oversight, inadequate budget and staffing models to meet growing demand, lack of unified practice policy and anticoagulation information systems, and lack of standardized quality measures and reporting. Vanderbilt leadership commissioned an Anticoagulation Executive Steering Committee to perform an operational redesign of the anticoagulation programs to meet National Patient Safety Goals. The committee appointed working groups to: evaluate and redesign clinical operations and finance, perform a technology assessment to develop standard anticoagulation information systems, and develop standardized reporting of quality metrics. The key redesign features were: 1) merging of the existing anticoagulation clinics into a single unified program; 2) dedicated institutional budget for ambulatory anticoagulation services with costs shared across the clinical enterprise; 3) implementation of standard policies and protocols for anticoagulation management and education; 4) creation of dedicated oral anticoagulation management software (AMS) fully integrated into the electronic health record; 5) creation of medical director and program manager positions for operational oversight of the unified program, and an Anticoagulation Oversight Committee for clinical practice supervision; 6) development of a bundle of quality metrics and operational/clinical data reports derived from the AMS. Our redesign experience provides a blueprint for other organizations that provide anticoagulation management to meet National Patient Safety Goals.
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Abstract
OBJECTIVE To evaluate contemporary hospital glycemic management in US academic medical centers. DESIGN This retrospective cohort study was conducted on patients discharged from 37 academic medical centers between July 1 and September 30, 2004; 1,718 eligible adult patients met at least 1 of the inclusion criteria: 2 consecutive blood glucose readings >180 mg/dL within 24 hours, or insulin treatment at any time during hospitalization. We assessed 3 consecutive measurement days of glucose values, glycemic therapy, and additional clinical and laboratory characteristics. RESULTS In this diverse cohort, 79% of patients had a prior diagnosis of diabetes, and 84.6% received insulin on the second measurement day. There was wide variation in hospital performance of recommended hospital diabetes care measures such as glycosylated hemoglobin (A1C) assessment (range, 3%-63%) and timely admission laboratory glucose measurement (range, 39%-97%). Median glucose was significantly lower for patients in the intensive care unit (ICU) compared to ward/intermediate care. ICU patients treated with intravenous insulin had significantly lower median glucose when compared to subcutaneous insulin. Only 25% of ICU patients on day 3 had estimated 6 AM glucose <or=110 mg/dL. Hyperglycemia was common, 50% of all patients had >or=1 glucose measurement >or=180 mg/dL on measurement days 2 and 3. Severe hypoglycemia (<50 mg/dL) occurred in 2.8% of all patient days. CONCLUSIONS Despite frequent insulin use, glucose control was suboptimal. Academic medical centers have opportunities to improve care to meet current American Diabetes Association hospital diabetes care standards.
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Affiliation(s)
- Jeffrey B Boord
- Veterans Affairs Tennessee Valley Health Care System, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-8802, USA.
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11
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Boord JB, Sharifi M, Greevy RA, Griffin MR, Lee VK, Webb TA, May ME, Waitman LR, May AK, Miller RA. Computer-based insulin infusion protocol improves glycemia control over manual protocol. J Am Med Inform Assoc 2007; 14:278-87. [PMID: 17329722 PMCID: PMC2244871 DOI: 10.1197/jamia.m2292] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Hyperglycemia worsens clinical outcomes in critically ill patients. Precise glycemia control using intravenous insulin improves outcomes. To determine if we could improve glycemia control over a previous paper-based, manual protocol, authors implemented, in a surgical intensive care unit (SICU), an intravenous insulin protocol integrated into a care provider order entry (CPOE) system. DESIGN Retrospective before-after study of consecutive adult patients admitted to a SICU during pre (manual protocol, 32 days) and post (computer-based protocol, 49 days) periods. MEASUREMENTS Percentage of glucose readings in ideal range of 70-109 mg/dl, and minutes spent in ideal range of control during the first 5 days of SICU stay. RESULTS The computer-based protocol reduced time from first glucose measurement to initiation of insulin protocol, improved the percentage of all SICU glucose readings in the ideal range, and improved control in patients on IV insulin for > or =24 hours. Hypoglycemia (<40 mg/dl) was rare in both groups. CONCLUSION The CPOE-based intravenous insulin protocol improved glycemia control in SICU patients compared to a previous manual protocol, and reduced time to insulin therapy initiation. Integrating a computer-based insulin protocol into a CPOE system achieved efficient, safe, and effective glycemia control in SICU patients.
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Affiliation(s)
- Jeffrey B Boord
- Vanderbilt University, Division of Cardiovascular Medicine, Nashville, TN 37232-8802, USA.
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12
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Abstract
Outcomes from recent lipid-lowering trials have led to an update of the third Report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel's guidelines for treatment of hypercholesterolemia in adults. The updated NCEP guidelines now offer an optional goal of low-density lipoprotein (LDL) cholesterol of less than 70 mg/dL for high-risk individuals. Epidemiologic and clinical trial data suggest that for every 30-mg/dL change in LDL, the relative risk for coronary heart disease changes by about 30%. Statin therapy effectively lowers LDL and has an overall excellent safety profile in clinical trials. However, the use of high-dose statin therapy also entails greater risk of adverse events, such as myopathy and liver function test abnormalities, and this must be carefully weighed against the potential benefit for each patient. Alternative approaches targeting high-density lipoproteins and triglycerides may offer yet another option for coronary heart disease prevention in high-risk patients.
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Affiliation(s)
- Anup K Sabharwal
- VA Tennessee Valley Geriatrics Research, Education, and Clinical Center, 1310 24th Avenue South, Nashville, TN 37212, USA
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13
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Boord JB, Maeda K, Makowski L, Babaev VR, Fazio S, Linton MF, Hotamisligil GS. Combined adipocyte-macrophage fatty acid-binding protein deficiency improves metabolism, atherosclerosis, and survival in apolipoprotein E-deficient mice. Circulation 2004; 110:1492-8. [PMID: 15353487 PMCID: PMC4027050 DOI: 10.1161/01.cir.0000141735.13202.b6] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The adipocyte fatty acid-binding protein (FABP) aP2 is expressed by adipocytes and macrophages and modulates insulin resistance, glucose and lipid metabolism, and atherosclerosis. Insulin sensitivity is improved in obese but not in lean aP2-deficient mice. A second fatty acid-binding protein, mal1, also is expressed in adipocytes and macrophages, and mal1 deficiency produces similar effects on insulin resistance. We tested the hypothesis that combined aP2 and mal1 deficiency would produce synergistic effects on metabolism and reduce atherosclerosis in apolipoprotein E-deficient (apoE-/-) mice. METHODS AND RESULTS Male and female apoE-/- mice null for both aP2 and mal1 (3KO) and apoE-/- controls were fed a low-fat chow diet for 16 or 56 weeks. Lean 3KO mice had significantly lower serum cholesterol and triglycerides as well as improved insulin and glucose tolerance as compared with controls. Analysis of atherosclerotic lesions in the 3KO mice showed dramatic reductions in both early (20 weeks) and late-stage (60 weeks) atherosclerosis. Strikingly, survival in the 3KO mice was improved by 67% as compared with apoE-/- controls when challenged with the Western diet for 1 year. CONCLUSIONS Combined aP2 and mal1 deficiency improved glucose and lipid metabolism, reduced atherosclerosis, and improved survival in apoE-/- mice, making these proteins important therapeutic targets for the prevention of the cardiovascular consequences of the metabolic syndrome.
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Affiliation(s)
- Jeffrey B Boord
- Research Department and Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, USA
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14
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Boord JB, Maeda K, Makowski L, Babaev VR, Fazio S, Linton MF, Hotamisligil GS. Adipocyte fatty acid-binding protein, aP2, alters late atherosclerotic lesion formation in severe hypercholesterolemia. Arterioscler Thromb Vasc Biol 2002; 22:1686-91. [PMID: 12377750 PMCID: PMC4027051 DOI: 10.1161/01.atv.0000033090.81345.e6] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The adipocyte fatty acid-binding protein, aP2, has important effects on insulin resistance, lipid metabolism, and atherosclerosis. Its expression in macrophages enhances early foam cell formation and atherosclerosis in vivo. This study was designed to determine whether aP2 deficiency has a similar effect in the setting of advanced atherosclerosis and severe hypercholesterolemia. METHODS AND RESULTS Mice deficient in aP2 and apolipoprotein E (aP2(-/-)apoE(-/-) mice) and apolipoprotein E-deficient control mice (apoE(-/-) mice) were fed a Western diet for 14 weeks. No significant differences in fasting serum levels of cholesterol, triglycerides, or free fatty acids were found between groups for each sex. Compared with apoE(-/-) control mice, male and female aP2(-/-)apoE(-/-) mice had significant reductions in mean atherosclerotic lesion size in the proximal aorta, en face aorta, and innominate/right carotid artery. Feeding the Western diet in the apoE-deficient background did not cause a significant reduction in insulin sensitivity in vivo, as determined by steady-state serum glucose levels and insulin tolerance testing. CONCLUSIONS These data demonstrate an important role for aP2 expression in the advanced stages of atherosclerotic lesion formation. Thus, aP2 provides an important physiological link between different features of the metabolic syndrome and is a potential target for therapy of atherosclerosis.
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Affiliation(s)
- Jeffrey B Boord
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn, USA
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Abstract
Cytoplasmic fatty acid-binding proteins (FABPs) are a family of proteins, expressed in a tissue-specific manner, that bind fatty acid ligands and are involved in shuttling fatty acids to cellular compartments, modulating intracellular lipid metabolism, and regulating gene expression. Several members of the FABP family have been shown to have important roles in regulating metabolism and have links to the development of insulin resistance and the metabolic syndrome. Recent studies demonstrate a role for intestinal FABP in the control of dietary fatty acid absorption and chylomicron secretion. Heart FABP is essential for normal myocardial fatty acid oxidation and modulates fatty acid uptake in skeletal muscle. Liver FABP is directly involved in fatty acid ligand signaling to the nucleus and interacts with peroxisome proliferator-activated receptors in hepatocytes. The adipocyte FABP (aP2) has been shown to affect insulin sensitivity, lipid metabolism and lipolysis, and has recently been shown to play an important role in atherosclerosis. Interestingly, expression of aP2 by the macrophage promotes atherogenesis, thus providing a link between insulin resistance, intracellular fatty acid disposition, and foam cell formation. The FABPs are promising targets for the treatment of dyslipidemia, insulin resistance, and atherosclerosis in humans.
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Affiliation(s)
- Jeffrey B Boord
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232-6300, USA
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MESH Headings
- Age of Onset
- Ambulatory Care/methods
- Ambulatory Care/trends
- Blood Glucose/analysis
- Cardiovascular Diseases/etiology
- Critical Care/methods
- Critical Care/trends
- Critical Illness/therapy
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/therapy
- Diabetes Mellitus, Type 2/classification
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/therapy
- Diabetic Ketoacidosis/etiology
- Drug Monitoring
- Humans
- Hyperglycemia/etiology
- Hyperglycemic Hyperosmolar Nonketotic Coma/etiology
- Hypoglycemia/etiology
- Hypoglycemic Agents/therapeutic use
- Insulin/therapeutic use
- Nutritional Support/methods
- Nutritional Support/trends
- Risk Factors
- Terminology as Topic
- Treatment Outcome
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Affiliation(s)
- J B Boord
- Department of Medicine, Vanderbilt University Medical Center, Tennessee Valley Veterans Affairs Medical Center, Nashville, Tennessee 37232, USA
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Makowski L, Boord JB, Maeda K, Babaev VR, Uysal KT, Morgan MA, Parker RA, Suttles J, Fazio S, Hotamisligil GS, Linton MF. Lack of macrophage fatty-acid-binding protein aP2 protects mice deficient in apolipoprotein E against atherosclerosis. Nat Med 2001; 7:699-705. [PMID: 11385507 PMCID: PMC4027052 DOI: 10.1038/89076] [Citation(s) in RCA: 537] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The adipocyte fatty-acid-binding protein, aP2, has an important role in regulating systemic insulin resistance and lipid metabolism. Here we demonstrate that aP2 is also expressed in macrophages, has a significant role in their biological responses and contributes to the development of atherosclerosis. Apolipoprotein E (ApoE)-deficient mice also deficient for aP2 showed protection from atherosclerosis in the absence of significant differences in serum lipids or insulin sensitivity. aP2-deficient macrophages showed alterations in inflammatory cytokine production and a reduced ability to accumulate cholesterol esters when exposed to modified lipoproteins. Apoe-/- mice with Ap2+/+ adipocytes and Ap2-/- macrophages generated by bone-marrow transplantation showed a comparable reduction in atherosclerotic lesions to those with total aP2 deficiency, indicating an independent role for macrophage aP2 in atherogenesis. Through its distinct actions in adipocytes and macrophages, aP2 provides a link between features of the metabolic syndrome and could be a new therapeutic target for the prevention of atherosclerosis.
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Affiliation(s)
- Liza Makowski
- Division of Biological Sciences and Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Jeffrey B Boord
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kazuhisa Maeda
- Division of Biological Sciences and Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Vladimir R Babaev
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - K Teoman Uysal
- Division of Biological Sciences and Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Maureen A Morgan
- Bristol-Myers Squibb PRI, Department of Metabolic Research, Princeton, New Jersey, USA
| | - Rex A Parker
- Bristol-Myers Squibb PRI, Department of Metabolic Research, Princeton, New Jersey, USA
| | - Jill Suttles
- Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Sergio Fazio
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Pathology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gökhan S Hotamisligil
- Division of Biological Sciences and Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
| | - MacRae F Linton
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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