Pathways to Quality Inpatient Management of Hyperglycemia and Diabetes: A Call to Action

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.Over the past decade, there has been increasing interest in glycemic management of hospitalized patients. There is now broad consensus that both hyperglycemia and hypoglycemia in hospitalized patients are associated with adverse outcomes, including mortality. There is less agreement, however, as to whether these associations actually reflect the effects of the quality of glucose management or are merely underlying paraphenomena of the severity of acute illness. Even more controversial is the actual potential impact of glycemic control during these hospitalizations that are often relatively brief, the specific glucose ranges that should be targeted, and the methods by which clinicians might achieve these.In the 1960s, research on the benefits of glucose-insulin-potassium infusion during acute myocardial infarction began, but this line of inquiry was not focused on glucose control per se (1). Interest in the general field of glycemic management in the inpatient setting began in the mid 1990s (2). The next 10 years were marked by both prospective observational trials and randomized clinical trials (RCTs), the majority of which seemed to indicate that “lower is better”: hospital complications, length of stay, cost, and even mortality could be dramatically decreased in a variety of critical care settings if mean glucose concentrations were reduced, usually with intravenous insulin, toward or within the euglycemic range (3,4). Some results, however, seemed too good to be true, especially in the context of such short hospital stays. This skepticism led to confirmatory trials, most conducted using a multicenter design. These could not confirm the initial positive findings from single-center investigations (5–7). There was resulting confusion as to how these results might shape clinical practice. Several consensus documents have emerged, each endorsing a more moderate approach to the management of glycemia in the hospitalized patient (8–11). Notably, all have called for more research in this area so that we can better understand the impact of both hyperglycemia and hypoglycemia on inpatient outcomes and better delineate evidence-based standards for hospital practice.To date, most investigations have been funded through local resources or industry, as agencies appear reluctant to commit financial support for research in inpatient glycemic management. However, greater efforts devoted to the study of diabetes in the hospital setting would have broad implications for our health care system (12). In addition to funding, the nascent discipline of inpatient glucose management will benefit from standardized nomenclature, consistent and meaningful metrics, and transparent study designs and analytical methods allowing for comparison of study outcomes.In this article, we outline eight aspects of inpatient glucose management in which RCTs and/or rigorously designed observational studies are needed. We refer to four as system-based issues and four as patient-based issues. Our goal was to identify existing research gaps and clinical care challenges in inpatient glucose management and to suggest future directions for each. These are summarized in Open in a separate window