Perioperative Diabetes Management Guidelines May Improve Care

NASHVILLE, Tenn. — Implementation of perioperative, multidisciplinary guidelines for managing diabetes may improve preoperative assessment of patients with diabetes, perioperative glucose monitoring, insulin use and glucose control, according to a new study presented at the American Association of Clinical Endocrinologists (AACE) 24th Annual Scientific & Clinical Congress.

The researchers also reported, however, that improvements resulting from following the guidelines decreased over time, and so greater efforts may be needed to encourage adherence to these types of guidelines.

“It is important to look at this issue because we know that hyperglycemia contributes to poorer surgical outcomes. It is worthwhile to assess measures that can improve glycemic control in the perioperative period,” said study investigator Maja Udovcic, MD, of the Mayo Clinic in Glendale, Arizona.

Udovcic and her colleagues analyzed key measures during 12 months after guidelines were introduced and compared those measures with a previously published 4-month historical cohort. For their investigation, the researchers looked at 254 surgical procedures in the historical cohort and 1,387 in the post-guideline implementation cohort.

The guidelines were developed and implemented by a team with representatives from endocrinology, surgery and anesthesiology. They were designed to improve perioperative management of patients with diabetes.

After guideline implementation, preoperative medical evaluations occurred in 85% of cases compared with 80% in the historical cohort (P=.045). HbA1c measurements were also obtained more often after implementation of the guidelines (72% vs. 47%; P<.01).

Similarly, glucose monitoring was performed in the preoperative area in 93% of cases after the guidelines were implemented vs. 88% in the historical cohort (P<.01).

Although the researchers were pleased to see these improvements, they noted that the frequency of measurements declined over the course of 12 months (95% vs. 91%).

Additionally, intraoperative glucose monitoring occurred in 67% of cases after guideline implementation vs. 29% in the historical cohort (P<.01). However, the frequency decreased during 12 months 67% vs. 55%; P<.01).

Results indicated no change in glucose monitoring in the postanesthesia care unit (PACU) after implementation of the guidelines (86% vs. 87%; P=.57), but frequency of monitoring also declined in a pattern similar to that seen in the preoperative and intraoperative areas (91% vs. 87%; P<.01).

“There are other quality improvement studies that assess the effect of strategies of glycemic control in the hospital and in the perioperative period. This is an assessment of our current practice and an attempt to improve the delivery of care,” Udovcic told Endocrinology Advisor.

“A multidisciplinary approach to improve glycemic control can be effective; however, it is difficult to sustain this improvement over time, and this is an area in need of further research.”

The study showed that insulin use increased in the preoperative, intraoperative and PACU areas after the guidelines were put in place. Even so, insulin was given in fewer cases by the end of 1 year than the period immediately following introduction of the guidelines (P<.01).

The researchers also found that the mean preoperative glucose was 128 mg/dL in the postguideline cohort compared with 141 mg/dL in the historical cohort (P<.01). Similar findings were also demonstrated in the PACU, where the mean values were 149 mg/dL in the postguidelines group compared with 162 mg/dL in the historical group (P<.01).

Although the improvements decreased during the study period, the rates did not fall below the historical period, according to Udovic. She said the overall study showed that implementing multidisciplinary diabetes management guidelines for patients with diabetes undergoing surgery can improve performance in key areas of care.

The next step, according to Udovic, is figuring out how best to address the problem with adherence.

“Implementing standards of care improved preoperative assessment of diabetes patients, perioperative glucose monitoring, insulin use and glucose control. Further research needs to be conducted on how to sustain adherence to guidelines,” Udovic said.

Reference

1. Udovic M et al. Abstract #206. Presented at: American Association of Clinical Endocrinologists (AACE) Annual Scientific & Clinical Congress; May 13-17, 2015; Nashville, Tenn.