Computer-Guided Insulin Titration Helps Hospitals Meet Basal Bolus Standard, Study Finds

A decade ago, the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) updated treatment guidelines for hospital patients outside the intensive care unit, after a study showed that administering basal-bolus insulin to these patients brought better glycemic control than sliding scale insulin,¹ which had been developed not long after the hormone’s discovery in 1921 as a treatment for diabetes.

Yet sliding sale insulin in hospital settings persists, largely because it’s easier to manage. Sliding scale insulin sets the dose strictly off a blood glucose level, without taking a number of personal factors into account. It can create the “rollercoaster” effect that is so dangerous for people with diabetes, and which basal bolus insulin seeks to avoid.

With basal bolus, the patient takes a long-acting (basal) insulin to keep blood sugar levels stable during periods without food, and a short-acting (bolus) at mealtime. This method offers the patient greater control but also requires more adjustments (for example, the nurse include food left on the tray in the calculation).

The movement toward quality ratings—and an increased emphasis on preventing readmissions—demanded solutions that help hospitals achieve the standard, which ADA clarified in January 2017 to state that basal bolus insulin was the preferred treatment for noncritically ill patients, and that, “Prolonged sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged.”²

An analysis of an electronic glucose management system developed by Glytec, which helps nurses safely manage basal bolus insulin dosing in the hospital, was presented at the recent meeting of the American Association of Clinical Endocrinologists (AACE) 26^th Annual Scientific and Clinical Congress, held in Austin, Texas. The study of 1687 patients at 9 hospitals, presented by Jagdeesh Ullal, MD, MS, of Sentara Healthcare and Eastern Virginia Medical School; and Joseph Aloi, MD, of Wake Forest Health, found that computer-guided system led to a 19% reduction in the average daily blood glucose level, while keeping most patients in the prescribed range of 140 mg/dL to 180 mg/dL.³

“Basal-bolus insulin management is the standard of care,” said Ullal. For a variety of reasons, however, 60% to 70% of hospital orders were still for sliding scale insulin, which Ullal said occurs simply because basal bolus is harder for health systems to do when they are concentrating on the main cause of the admission.

With technology, however, “we’re ushering in that change.”

In an interview with The American Journal of Managed Care®, Ullal said the Glytec system, called the Glucommander, brought major improvements in the average daily blood glucose levels.

of patient days of severe hypoglycemia (<40 mg/dL) was 0%. According to the abstract, the percentage of patient days with hyperglycemia (>250 mg/dL) was 11.29%.³

The next step, according to Ullal and Raymie McFarland, Glytec's vice president of Quality Initiatives and Clinical Excellence, is to calculate how the imprved glucose management for this population translates into cost savings and reduced readmissions. Previous studies of other populations using the Glucommander have shown improvements in these areas.

Patients’ average levels dropped from 204.88 mg/dL at admission, well out of range, compared with an average of 165.80 mg/dL by the time they were discharged, after an average of 5.9 days. Ullal said use of the electronic system allowed the hospitals to keep the percentage of patient days with mild to moderate hypoglycemia (<70 mg/dL but >40 mg/dL) at 0.08%, while the percentage

References

1.Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care. 2007; 30(9):2181-2186.

2. American Diabetes Association. Standards of Medical Care in Diabetes—2017.Diabetes Care. 2017;40(suppl1):127.

3. Aloi J, Ullal J, Chidester P, McFarland R. AUTO: AUtomatic Titration tO Target: subcutaneous basal bolus insulin management using eGMS in the non-ICU setting. Presented at the 26^thAnnual Clinical and Scientific Congress, Amercan Association of Clinical Endocrinologists, Austin, Texas; May 4, 2017.