Annals for Educators - 2 May 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives2 May 2017Annals for Educators - 2 May 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201705020 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAssociation Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients. An Observational StudyDiabetes mellitus or uncontrolled hyperglycemia is common among inpatients and is associated with adverse outcomes. This study assessed the effect of a virtual glucose management service on inpatient glycemic control.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what effects hyperglycemia has on outcomes among hospitalized patients.How do your learners choose a glycemic target range for a hospitalized patient? What variables might alter their goals?What medications do you use, and in what manner? Do you use a basal–bolus approach? Why?What variables pose particular challenges to ideal glucose control in the hospital (e.g., changes in the timing of meals, concurrent metabolic derangements, fasting for procedures)? Use the accompanying editorial to help frame your discussion.Present serial glucose measurements together with recent medication administration and nutritional intake information on a few theoretical patients to prompt discussion of what, if any, alteration in therapy might be appropriate for each. You might show the flow sheet in Appendix Figure 2 of the article as an example for discussion. What would your learners have done in response to the blood glucose reading of 310 mg/dL?Review the diabetic flow sheets of patients on your service. Is there adequate glycemic control? Are there regularly occurring problems that your team can identify? How might they be remedied?In the Clinic: Polymyalgia RheumaticaPolymyalgia rheumatica is a common, chronic, systemic rheumatic inflammatory disease that affects adults older than 50 years. Although symptoms of proximal muscle stiffness and elevated inflammatory markers are typical, there are no specific diagnostic features. Are your learners prepared to recognize patients presenting with possible polymyalgia rheumatica?Use this review to:Ask your learners what the possible symptoms of polymyalgia rheumatica are. Use the box on page ITC67.What physical examination findings should be considered? What is seronegative symmetrical synovitis with pitting edema?What is the differential diagnosis of polymyalgia rheumatica? Why is it important to differentiate it from giant cell arteritis, for example? How does the specific diagnosis alter short- and long-term management?In whom should an ultrasound be considered? Should other tests be considered? Which ones?How is therapy approached? When should steroids be started, and when should they be tapered? When should other agents be considered? When is consultation with a rheumatologist appropriate?Use the teaching slides to help prepare for a teaching session. Break up the teaching session with the multiple-choice questions, and be sure to log on to enter your answers to earn CME credit for yourself!Understanding Clinical ResearchAnnals Understanding Clinical Research: Intention-to-Treat AnalysisThis brief tutorial helps clinicians assess the clinical relevance of results from intention-to-treat analyses and decide whether results from additional analyses may be helpful.Use this paper to:Ask your learners to define bias as it relates to the results of a study aiming to assess whether a treatment improves an outcome. How does randomization in a trial help to minimize bias?What does (or should) it mean when one reads “intention to treat” in the report of a randomized clinical trial? Why might crossover from one assigned treatment group to another or some participants' failure to adhere to their assigned treatment protocols bias the results? Does an intention-to-treat analysis ensure that such bias does not affect the reported results and conclusions? The authors explain why it does not.Ask your learners what the authors mean when they write that an “as-treated” analysis would not be “protected by the randomization.” What bias would be introduced with a “per protocol” analysis? Why do these details matter when assessing how the analysis was performed and reported in a paper?Our Health Care System: Hassles and SolutionsAnnals Graphic Medicine: Anatomy of a Donut HolePutting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of PhysiciansA Tale of Two Countries: How I Saw More Patients With More Joy in Internal Medicine PracticeDesigning and Regulating Wisely: Removing Barriers to Joy in PracticeExcessive administrative tasks divert time and focus from more clinically important tasks. This Annals Graphic Medicine piece (a comic!) tells the familiar story of how a patient—and his doctor—became trapped within a bureaucratic system and how it affected the care the patient received. The position paper offers a framework to evaluate administrative tasks and recommendations to reduce excessive administrative duties in health care. The essay contrasts the experience of practicing general internal medicine in Australia with that in the United States and explains why the author experienced more joy in practice in Australia. The editorial discusses the negative consequences of excessive administrative tasks and views the ACP's recommendations as a timely call for greater evidence-based regulation and a shared responsibility to create better value in health care.Use these pieces to:Show the Annals Graphic Medicine piece to your learners. Ask them if they can relate to how the author feels. Does it make them laugh? Feel angry? Feel sad? All three?Do your learners understand the “donut hole”? To whom should they turn for help in figuring out such issues? Is there adequate support for patients and clinicians at your center with “administrative tasks”?What are the benefits of preauthorizations and approvals for treatments? What are the harms? Use the editorial to help frame your discussion.How would your learners design a system that might better balance necessary and helpful administrative controls and their potential harms? Do your learners think a model such as Australia's is better? Do they think the framework proposed by the ACP to evaluate the value of an administrative task is a good one?Do your learners worry that administrative hassles might drive them away from practicing medicine? How can they deal with them? Can they help bring about change?Make a list of the administrative tasks in clinical care specific to your hospital only (e.g., a form to place an order). What is the purpose of each? Can your learners identify tasks that might be safely eliminated without causing a problem? Can they propose a more efficient alternative approach? To whom should they take their ideas within your health system?MKSAP 17 QuestionA 57-year-old man is admitted to the hospital for evaluation of substernal chest pain. His medical history is significant for type 2 diabetes mellitus, coronary artery disease, hypertension, and hyperlipidemia. He manages his diabetes as an outpatient with diet, exercise, and metformin. His other medications are aspirin, metoprolol, atorvastatin, and sublingual nitroglycerin as needed. His inpatient plasma glucose values are 170 to 210 mg/dL (9.4-11.6 mmol/L). Results of all other laboratory studies are normal.Which of the following is the most appropriate treatment for this patient's diabetes while hospitalized?A. Basal and prandial insulinB. GlipizideC. MetforminD. Sliding-scale insulinCorrect AnswerA. Basal and prandial insulinEducational ObjectiveManage diabetes mellitus in a hospitalized patient.CritiqueThe most appropriate treatment for this patient's diabetes mellitus while hospitalized is a weight-based treatment plan that includes basal and prandial insulin. Hyperglycemia in the hospital is associated with poor outcomes. According to the American Diabetes Association and American Association of Clinical Endocrinologists, glucose goals in hospitalized patients in a non-ICU setting are premeal values less than 140 mg/dL (7.8 mmol/L) and random values less than 180 mg/dL (10 mmol/L). The American College of Physicians recommends avoiding values less than 140 mg/dL (7.8 mmol/L) to decrease the risk of hypoglycemic complications. The patient's plasma glucose values exceed the recommended guidelines and require treatment.Oral agents do not have safety or efficacy data for use in the hospital. Glipizide is an insulin secretagogue that can potentially induce hypoglycemia in the hospital setting, particularly with unpredictable changes in oral intake.With metformin use, hospitalized patients can develop poor organ perfusion, which can increase the risk of lactic acidosis. Intravenous contrast dye can also impair kidney function in the setting of metformin use in the hospital. Reinitiation of the patient's home regimen of metformin at or near the time of discharge is most appropriate after all procedures have been completed and organ function is stable and glucose levels have returned to baseline values.Sliding-scale insulin is nonphysiologic and can result in large fluctuations in blood glucose levels. Sliding-scale insulin is not recommended as the sole insulin therapy in the hospital setting.Key PointFor non-critically ill hospitalized patients with diabetes mellitus and hyperglycemia, a weight-based treatment plan that includes basal and prandial insulin is recommended.BibliographyAmerican Diabetes Association. (13) Diabetes care in the hospital, nursing home, and skilled nursing facility. In: Standards of Medical Care in Diabetes-2015. Diabetes Care. 2015 Jan;38 Suppl:S80-5.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 2 May 2017Volume 166, Issue 9Page: ED9KeywordsDiabetes mellitusGlucoseHealth careHyperglycemiaInpatientsInsulinIntent to treat analysisPatientsPolymyalgia rheumaticaTreatment guidelines ePublished: 2 May 2017 Issue Published: 2 May 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...