The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.
Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.
As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.
The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.
Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.
Glycemic Control Issues
“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”
“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.
Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.
In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.
The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.
Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.
The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.
“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH