Close Concerns and diaTribe covered Glytec co-founder Dr. Bruce Bode’s presentation ATTD 2020 (Advanced Technologies & Treatments for Diabetes) as he explored the past, present and future of automated glucose control systems in hospital settings
Dr. Bruce Bode summarized decades of experience in delivering automated glucose control in the hospital setting. As background, Dr. Bode co-founded Glytec, a company offering the Glucommander glucose management system, which is currently in use by over 200 hospitals. The system, which covers the ER, ICU, step-down wards, discharge, and the transition to insulin at home, decreases mortality and complications and saves money, regardless of the underlying condition. In his talk, Dr. Bode covered the checkered history of glucose control in the ICU, noting that while normoglycemia radically improves outcomes, hospitals struggle to deliver it without increases in hypoglycemia. Given the practical limitations of the hospital setting, the logical approach to this problem is an automated system that takes glucose from meter readings and provides specific dosing recommendations. A plethora of data established that these systems save nursing time, decrease complications, decrease re-admission rate and complications after surgery. Despite this, only about 10% of hospitals use such a system, although it seems inevitable that they will become the standard of care.
- In 2001, a seminal paper by Van Den Berghe established that controlling glucose in the ICU leads to dramatic reductions in mortality (about 30-40%) and improvements in a whole range of complications, such as infection. Many hospitals tried to replicate these results, leading to the classic NICE-SUGAR study in 2009, which yielded the frustrating result that attempting to attain normoglycemia across a broad range of ICU settings increased the rate of death. After the fact it became clear that it was hypoglycemia that caused the excess death. Many hospitals simply didn’t have the tools to lower glucose safely. Consequently, this led to the weakening of ADA recommendations for glucose in the ICU. Prior to 2001, average glucose was above 200 mg/dl, but from 2001-2007 the ADA target was 80-110 mg/dl, which was then relaxed after NICE SUGAR to 140-180 mg/dl.
- In the United States, CMS is on the verge of imposing penalties on hospitals that cause hypoglycemic events.CMS is developing a hypoglycemia measure (<40 mg/dl and five or more minutes before the patient gets back to 80 mg/dl) for which they will require reporting and ultimately will levy a fine.
- For all these reasons, reducing insulin-induced hypoglycemia is a critical issue.It’s remarkable to note that in a typical hospital, 40% of inpatients require insulin at some point. In the first place, 25% of all inpatient days are people with diabetes. 6% of hospitalized patients experience hypoglycemia, and readmission rates for people with diabetes are 20%. In a study at Florida Hospital, if a patient goes under 40 mg/dl at any point during their stay, it was found to cost an additional $10,000 and add about seven days to the length of stay. Mortality is also about three times higher. In Florida Hospital, severe or moderate hypoglycemia cost an excess of $45.6m over a twelve month period, which was largely eliminated using an automated system.
- Given the inadequacy of current systems, an automated glycemic management system is the best approach for managing hyperglycemia and avoiding hypoglycemia. Currently, less than 10% of all hospitals are using such a system. Commercial computerized systems include Glytec, EndoTool, GlucoCare and Glucostabilizer. Dr Bode’s company, Glytec offers an extended glucose management system (called an eGMS) that covers the ER, ICU, step down ward, long term acute care (LTAC), skilled nursing facilities (SNF), and the discharge process and enables the transition to insulin at home. The system also integrates tightly with EMR and ICU systems.
- The Glytec Glucommander system provides strong benefit, including time saved for nurses, cost savings to the hospital, and reduced readmission rates.In a test of the system at Kaweah Delta Medical Center, sliding-scale insulin management was almost completely replaced with eGMS, leading to a reduction in whole-stay average glucose from 204 mg/dl to 165 mg/dl, a 25% reduction in hypoglycemia under 70 mg/dl and a 75% reduction in hypoglycemia under 40 mg/dl. Length of stay was reduced by 25% and cost savings were $10m. In another example of patients admitted for diabetic ketoacidosis, the automated system reduced time spent above 200mg/dl from 17 hours to 14 hours and saved 1.5 days in the hospital per event.
- Bode highlighted a study of automated glucose control following coronary artery bypass surgery (CABG) that yielded a 20% improvement in complications and 60% less readmission.Although cardiologists were initially very concerned about insulin induced hypoglycemia, the intervention caused no hypoglycemia at all. Patients ended up with an average glucose of 132 mg/dl versus 154 mg/dl in the standard of care comparator. The cost of hospitalization was 10.3% lower in the intervention group.
- On discharge, an automated system can determine insulin requirements at home. Controlling glucose at home prevents re-admissions.For the hospital to home transition they system advises on the need for insulin and provides dosing information for basal/bolus.
Selected Questions and Answers
Q: What type of glucose measurements do you make?
A: There are only two point of care meters approved in our hospitals at present - Novo Biomedical and Roche. We are testing some CGM solutions, but we don’t have it in the product at this time
Q: Have you used the technology in an outpatient setting?
A: Yes, we have used it for titration of MDI and it works well. We are conducting a study with Abbott Libre. The system provides feedback by texting to their phone. A CDE also provides support for 500 patients.
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