Clinical analysis of inpatients with hyperglycemia in the medical intensive care units——Data of Shanghai Renji Hospital from 2002 to 2009

Objective To analyze the association of the morbidity,the management of blood glucose,and the prognosis of patients with hyperglycemia in the medical intensive care units(ICU).Methods Medical records of ICU patients of Renji Hospital from 2002 to 2009 were reviewed using Medical Record Inquiry System,and the data were retrospectively analyzed.Results(1)2631 subjects were included in the present study,blood glucose was determined at least once during hospitalization in 2168 of them.The incidence of hyperglycemia was 26.3%,in which 12.9% presented a known history of diabetes and 13.4% without.In the patients with diabetes history,93.2% of them received anti-diabetic treatment during hospitalization.mainly with oral anti-hyperglyeemic agents (53.0%)or subcutaneous insulin injection(24.9%).However,in the patients without diabetes history,84.4% were not treated against hyperglycemia.The mortality was increased in the latter group(30.4% vs13.9%,P<0.01).(2)In the patients with diabetes history,the mortality in patients whose blood glucose>10 mmol/L was higher than those with blood glucose≤7.0 mmol/L(20.5% vs 9.9%,P<0.05):while in the patients without diabetes history,the mortality began to rise as blood glucose>7.0 mmol/L(P<0.01).(3)Multiple stepwise regression analysis revealed that the average blood glucose level was an independent risk factor for death(OR=1.26).Conclusions The ICU patients showed a high prevalence of hyperglycemia,the management of hyperglycemia should be emphasized.Hyperglycemia in critically ill patients might be an independent risk factor of increased mortality.     

重症监护病房患者的个体化血糖管理

现在越来越多的证据提示重症监护病房(ICU)患者的血糖管理需要采取个体化血糖管理策略.针对ICU患者个体制定控糖目标时,除了需要考虑疾病种类之外,患者既往是否存在糖尿病病史也应当得到更多的关注.本文针对这一话题进行简要的文献复习和评论.     

重症监护病房患者的个体化血糖管理

现在越来越多的证据提示重症监护病房(ICU)患者的血糖管理需要采取个体化血糖管理策略.针对ICU患者个体制定控糖目标时,除了需要考虑疾病种类之外,患者既往是否存在糖尿病病史也应当得到更多的关注.本文针对这一话题进行简要的文献复习和评论.     

Clinical analysis of inpatients with hyperglycemia in the medical intensive care units——Data of Shanghai Renji Hospital from 2002 to 2009

Objective To analyze the association of the morbidity,the management of blood glucose,and the prognosis of patients with hyperglycemia in the medical intensive care units(ICU).Methods Medical records of ICU patients of Renji Hospital from 2002 to 2009 were reviewed using Medical Record Inquiry System,and the data were retrospectively analyzed.Results(1)2631 subjects were included in the present study,blood glucose was determined at least once during hospitalization in 2168 of them.The incidence of hyperglycemia was 26.3%,in which 12.9% presented a known history of diabetes and 13.4% without.In the patients with diabetes history,93.2% of them received anti-diabetic treatment during hospitalization.mainly with oral anti-hyperglyeemic agents (53.0%)or subcutaneous insulin injection(24.9%).However,in the patients without diabetes history,84.4% were not treated against hyperglycemia.The mortality was increased in the latter group(30.4% vs13.9%,P<0.01).(2)In the patients with diabetes history,the mortality in patients whose blood glucose>10 mmol/L was higher than those with blood glucose≤7.0 mmol/L(20.5% vs 9.9%,P<0.05):while in the patients without diabetes history,the mortality began to rise as blood glucose>7.0 mmol/L(P<0.01).(3)Multiple stepwise regression analysis revealed that the average blood glucose level was an independent risk factor for death(OR=1.26).Conclusions The ICU patients showed a high prevalence of hyperglycemia,the management of hyperglycemia should be emphasized.Hyperglycemia in critically ill patients might be an independent risk factor of increased mortality.     

Impact of a Care Manager on the Outcomes of Higher Risk Asthmatic Patients: A Randomized Controlled Trial

Asthma care management programs may improve outcomes, but it is not clear which aspects of such management are responsible for the improvement. We performed a randomized controlled trial of a limited intervention (one visit with asthma self-management education and provision of inhaled budesonide) compared to this visit plus regular asthma care manager follow-up. Quality of life, symptom-free days, emergency hospital care, and beta-agonist dispensings did not differ between groups at 12 months. Patients who entered the study did receive significantly less beta-agonists in the follow-up year than patients who did not enter the study. These data suggest that the limited intervention in our setting improved outcomes but that regular care manager follow-up thereafter did not add significantly to this intervention.     

Impact of a Care Manager on the Outcomes of Higher Risk Asthmatic Patients: A Randomized Controlled Trial

Asthma care management programs may improve outcomes, but it is not clear which aspects of such management are responsible for the improvement. We performed a randomized controlled trial of a limited intervention (one visit with asthma self-management education and provision of inhaled budesonide) compared to this visit plus regular asthma care manager follow-up. Quality of life, symptom-free days, emergency hospital care, and beta-agonist dispensings did not differ between groups at 12 months. Patients who entered the study did receive significantly less beta-agonists in the follow-up year than patients who did not enter the study. These data suggest that the limited intervention in our setting improved outcomes but that regular care manager follow-up thereafter did not add significantly to this intervention.     

Care Management Dosage

Background The care of patients with complex illnesses requires careful management, but systems of care management (CM) vary in their structure and effectiveness. Objective To create a framework identifying components of broad-based CM interventions and validate the framework, including using this framework to evaluate the contribution of varying components on outcomes of patients with chronic illness. Design We create the framework using retrospective information about CM activities and services over 12 months and categorize it using cluster and factor analysis. We then validate this framework through content and criterion techniques. Content validity is assessed through a Delphi study and criterion validity through relationship of the dosage measures and patterns of care to process and outcomes measures. Participants Patients with diabetes and/or cardiovascular disease receiving CM services in a model known as Care Management Plus implemented in primary care. Results Six factors of CM activity were identified, including a single dosage summary measure and 5 separate patterns of care. Of these, the overall dosage summary measure, face-to-face time, duration of follow-up, and breadth of services were all related to improved processes for hemoglobin A1c and LDL testing and control. Brief intense patterns of care and high face-to-face care manager time were also related to improved outcomes. Conclusions Using this framework, we isolate components of a CM intervention directly related to improved process of care or patient outcomes. Current efforts to structure CM to include face-to-face time and multiple diseases are discussed.     

Reductions in costly healthcare service utilization: findings from the Care Advocate Program

OBJECTIVES: To determine whether a telephone care-management intervention for high-risk Medicare health maintenance organization (HMO) health plan enrollees can reduce costly medical service utilization. DESIGN: Randomized, controlled trial measuring healthcare services utilization over three 12-month periods (pre-, during, and postintervention). SETTING: Two social service organizations partnered with a Medicare HMO and four contracted medical groups in southern California. PARTICIPANTS: Eight hundred twenty-three patients aged 65 and older; eligibility was determined using an algorithm to target older adults with high use of insured healthcare services. INTERVENTION: After assessment, members in the intervention group were offered mutually agreed upon referrals to home- and community-based services (HCBS), medical groups, or Medicare HMO health plan and followed monthly for 1 year. MEASUREMENTS: Insured medical service utilization was measured across three 12-month periods. Acceptance and utilization of Care Advocate (CA) referrals were measured during the 12-month intervention period. RESULTS: CA intervention members were significantly more likely than controls to use primary care physician services (odds ratio (OR)=2.05, P<.001), and number of hospital admissions (OR=0.43, P<.01) and hospital days (OR=0.39, P<.05) were significantly more stable for CA group members than for controls. CONCLUSION: Results suggest that a modest intervention linking older adults to HCBS may have important cost-saving implications for HMOs serving community-dwelling older adults with high healthcare service utilization. Future studies, using a national sample, should verify the role of telephone care management in reducing the use of costly medical services.     

What Can Improve Chronic Disease Care?

Chronic disease care is a central part of geriatrics. The rise in chronic disease draws attention to the need to find better ways to deliver effective care. This essay examines the effectiveness of several strategies for providing better chronic disease care, reviewing the literature and relying on extant reviews whenever possible. The evidence of effectiveness is mixed; a few areas show promise. The case for cost‐effectiveness is even less strong. New strategies may be indicated, including more‐proactive monitoring of clinical courses and assessing patients' readiness to participate actively in their own care.     

A survey of the primary care management of osteoarthritis in Malaysia: a view from a rheumatologist's perspective

Objective: Primary care management of knee osteoarthritis (OA) has received little attention in the scientific literature and the main reason for this survey is to study and explore the variations and patterns of primary care management and assess both conventional and complementary therapy usage in knee OA in the primary care setting. Methods: A cross‐sectional survey of 200 randomly selected general practitioners (GPs) in the peninsular states of Malaysia was undertaken using a questionnaire. The GPs involved were asked about basic knowledge of OA in terms of diagnosis, investigation, and treatment. They were also asked about their usage of conventional and complementary medication. Results: One hundred and eighty (90%) GPs responded to the questionnaires sent: 77% were in solo practice and 33% in group practice. Most of the GPs surveyed (60%) had been in practice for more than 10 years, 30% for 5–10 years and 10% were in practice for less than 5 years. Of GPs surveyed, 55% saw an average of more than 20 patients per week, 35% about 10–20 patients and 10% less than 10 patients per week. Of GPs surveyed, 65% would arrange an X‐ray, 55% would arrange a blood test, mostly serum uric acid, rheumatoid factor and erythrocyte sedimentation rate. Pharmacological management consists of first‐line treatment with non‐steroidal anti‐inflammatory drugs (NSAIDs) (61%), analgesics (35%) or a combination of the two (4%). Non‐pharmacological management consisted of advice on exercise (27%), weight reduction (33%) and referral to physiotherapy (10%). Of GPs surveyed, 85% prescribed some form of complementary medications, 60% prescribed glucosamine sulphate, 21% chondroitin sulphate, 11% cod liver oil and 9% evening primrose oil. Only 10% of GPs surveyed perform intra‐articular injections. Conclusion: The data suggest that in the primary care setting, the majority of GPs over‐investigate the diagnosis of OA. Pharmacological interventions largely concentrate on analgesics and NSAIDs. The use of physiotheraphy and non‐drug approaches were significantly under‐utilized. There is a need to further educate GPs in the management of OA.     

Provision of care to the terminal ill in the home: Community experiences in Japan

An analysis of the costs of terminal care in Japan revealed that the last month of life accounted for almost one-third of the costs incurred by patients during the entire preceding 10 months. In order to reduce the costs of terminal care and raise the level of care provided in the community two groups, an urban group led by Dr. Sato and a rural group led by Dr. Asai, developed innovative approaches for providing community care to terminal cancer (and other) patients. Three case studies illustrate the way the terminal stages of illness are managed under these new approaches. The authors conclude by proposing several reforms to improve the delivery of care to the terminally ill.     

Primary care physicians’ experience with disease management programs

OBJECTIVE: To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN: Cross-sectional mailed survey. SETTING: The 13 largest urban counties in California. PARTICIPANTS: General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS: Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction.     

Redefining and Redesigning Hospital Discharge to Enhance Patient Care: A Randomized Controlled Study

BACKGROUND  Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge process may improve the continuity and the quality of patient care. OBJECTIVES  To evaluate a low-cost intervention designed to promptly reconnect patients to their “medical home” after hospital discharge. DESIGN  Randomized controlled study. Intervention patients received a “user-friendly” Patient Discharge Form, and upon arrival at home, a telephone outreach from a nurse at their primary care site. PARTICIPANTS  A culturally and linguistically diverse group of patients admitted to a small community teaching hospital. MEASUREMENTS  Four undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and historical controls. RESULTS  Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls. CONCLUSIONS  A low-cost discharge–transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital discharge.     

Partnering managed care and community-based services for frail elders: the care advocate program

OBJECTIVES: To describe a demonstration program that uses master's-level care managers (care advocates) to link Medicare managed care enrollees to home- and community-based services, testing whether referrals to noninsured services can reduce service usage and increase member satisfaction and retention. DESIGN: Using an algorithm designed to target frail, high-cost users of Medicare insured healthcare services, the program partners PacifiCare's Secure Horizons and four of its medical groups with two social service organizations. SETTING: Three care advocates located in two community-based social services agencies using telephone interviews to interact with targeted elders living in the community. PARTICIPANTS: Three hundred ninety PacifiCare members aged 69 to 96 receiving care from four PacifiCare-contracted medical groups. INTERVENTION: The 12-month intervention provides telephone assessment, links to eight types of home- and community-based services, and monthly follow-up contacts. MEASUREMENTS: Sociodemographic characteristics of intervention participants, types of service referrals, and acceptance rates. RESULTS: Lessons learned included the importance of building a shared vision among partners, building on existing relationships between members and providers, and building trust without face-to-face interactions. CONCLUSION: The program builds on current insured case management services and offers a practical bridge to community-based services.