Brian Zimmerman  00:00

Hi everyone, and thanks for tuning in to the Becker's health care podcast series. I'm Brian Zimmerman, senior director, client content and strategy with Becker's hospital Review. Today I'm pleased to be joined by Dr. Joseph Aloi professor of Internal Medicine and chief of the endocrine diabetes and metabolism section at Wake Forest Baptist Medical Center. Dr. Aloi has been interested in methods to help improve the quality of care and quality of life for persons struggling to manage hyperglycemia. He's an active investigator and bringing technology to help improve the care of persons with diabetes. Dr. Aloi, thanks so much for joining us today.

Joseph Aloi  00:34

Happy to be here. Thanks for the invitation.

Brian Zimmerman  00:37

Absolutely. So let's dive right in here. My first question for you is what is diabetes ketoacidosis? And how does it impact patients in the hospital?

Joseph Aloi  00:46

Diabetes ketoacidosis or DKA is sort of a perfect storm of two main hormones, primarily affecting patients with type one diabetes. But type two diabetic patients can also have ketoacidosis. It's the combination of insulin deficiency, which can be absolute or relative, and a little bit of glucagon excess, and we all sort of are familiar with insulin and that it lowers blood sugar. And if there's an absence, we can expect the blood sugar to rise or hyperglycemia. Many of us aren't as familiar with glucagon. But glucagon is what normally is keeping our blood sugar up overnight. So it actually raises blood sugar. So it's a clinical situation where two hormones that are supposed to be acting, in concert, actually both work to drive, the blood sugar's up. Frequently, it's accompanied by a lot of dehydration because the blood sugar is up and it stays up. And it requires hospitalization and in many hospitals requires an intensive care unit to manage the hyperglycemia within intravenous insulin infusion. The work I do as an endocrinologist working on inpatient unit. This is a frequent patient we see. And generally speaking, our hospital, our main hospitals, about 800 beds, and we see between 20 and 30 cases of this a month. So 300 to 400 per year. So it's common, and it can be potentially life threatening.

Brian Zimmerman  02:29

Thank you for setting stage with those comments there. I personally wasn't aware of just how common This is. I know you recently co authored the first large scale study that sort of analyzed the characteristics of and sort of mortality associated with decay among us patients hospitalized with or without COVID-19. Can you talk about the results of this large scale study?

Joseph Aloi  02:51

Sure, it came out in March in JAMA open network. And really, it came about as a consequence of a couple conversations between Fransisco Pasquale, who's at Emory and as some of his partners there. And myself, we've been interested in DK, we've written some other papers about quality metrics to improve DK and folks at Glytec that have a, for lack of a better word, maybe a data warehouse on patients treated with IV insulin for DKA.

Joseph Aloi  04:48

Of that population, You know, we have so much emphasis on COVID. You think everybody would have COVID but it was about 210 patients or 4%. And the first cut of the data which really Got our attention as we just arbitrarily, if you will pick the young is 45 or less 45 to 65 is a middle age group and older 65 or greater and looked at the mortality. And those patients that came in with COVID versus those that did not. Now, as I stated earlier, I do this a lot. In my practice, I may have seen 234 patients die with DK, it's generally, you would, quote an estimate of about 2% mortality. And that's what we saw in the young group, the older group was a little bit higher around 12, or 14%. But if you looked at the COVID, group, 65, and older, their mortality was 45%, which was just dramatic. And if you say if almost half of those patients were dying.

Joseph Aloi  05:54

We then had an opportunity. And you know, the data sets are limited, you're restricted looking at labs that come through, and diagnoses but what we could tell. And we wouldn't be surprised, because when we think of COVID, and its impact on patients and hospitalization, they have a, quote cytokine storm, which is another way of saying they have a huge inflammatory response, which can increase their insulin requirements. So that patients in the COVID group required more insulin, they were treated longer, they had more impact on some acute kidney injury. But importantly, I think there wasn't a big difference in hypoglycemia between the two groups. And the exact reasons for the change mortality is it's not quite, you can't isolate it singularly down just a COVID. But they COVID really presents the patient coming into the hospital with much more serious illness. I think where we're using that information, I part of my job is helping to teach residents and we brought up this article just as a way of not having people be complacent with a common diagnosis with a previously relatively low mortality for patients coming to an ICU and wanting to refocus them that you have to be very vigilant with these patients. Because coming in, you've identified a very high risk patient for bad outcomes.

Brian Zimmerman  07:30

Some fascinating results there and the mortality there among COVID group is pretty striking. I want to ask them, you know, you sort of talked about how you really had to talk to your groups and have them focus on on on this problem, the pandemic course many hospitals to sort of adapt and change their protocols. Do you think that impacted how DK was treated? Can Can you talk more about that?

Joseph Aloi  07:53

The short answer, yes, the short answer is, I don't think so. And the indirect ways we had looking at was, was there a delay in blood sugar measurements, that was sort of an indirect way of looking at where these patients because they had COVID being touched less now, not in this study group that I can say for sure. Because we don't have a particular way of knowing how patients were actually managed at the bedside in a particular hospital. But when you look at our hospital, if you look at I was partnering with a provider in Houston medical Mount Sinai, there was a big implementation of protocols to teach to excuse me to treat more patients on the floors with subcutaneous insulin. Well, that patient group would have been included in this analysis because it was all IV insulin. So as much as I could say standard of cares, standard of care was given there was a statistically significant difference in delay and timing of blood glucoses. But it really clinically wasn't. In my mind, it was, if you looked at a percent, it was about a 7% versus 10% delay, which I don't think is clinically significant. Although given the numbers, it was statistically significant.

Joseph Aloi  09:19

Going back to some of the things that other hospital systems did in their ICU's, is they introduced continuous glucose sensors and continuous glucose monitoring as a way to decrease the frequency that someone would have to get a blood glucose measurement from a patient.

Joseph Aloi  09:39

Standard of care has been IV insulin, initiate with hourly blood sugar checks. This patient group all used Glucommander an embedded insulin dosing calculator within an EMR which after the blood glucose becomes relatively stable can spread that out to two hours. Some hospital systems were using sensors as a guide to see if they could start doing blood glucose tests and patients on IV insulin every two to three to four hours or use the glucose sensor as a cue, whether they should do a quick check of a blood sugar, I can tell you I don't know if I know the data and glucose sensors have been reported. I don't know of a large body of evidence data that's been published to say this, how common This is. I don't think that would have impacted this group again, because of the way it was all being managed through the embedded EMR Glucommander app.

Brian Zimmerman  10:45

Got it. Got it. Well, thanks for the added clarity there. And you mentioned sensors and monitor monitoring, of course being used here. Can you talk more about the kinds of technology hospitals should be looking forward to achieve best practices and really drive clinical change?

Joseph Aloi  11:01

Sure, I mean, this is something I'm interested in. And this is something that's evolving, as we speak, quite literally, it was almost probably was a year give or take a week ago exactly was last April when the FDA gave emergency use authorization for using sensors that were approved for use in the outpatient arena for use on the inpatient. And those papers are just coming out, we have a paper in prep, I've just reviewed another paper looking at this, there's several published. Again, the Emory group is very active in this area, they published more on a research side, showing that you could safely do this, there were some parameters that would make you want to do a blood glucose check to confirm a sensor check. But I think that eventually is going to become I don't want to say standard of care, but incorporated into usual care, there are clearly patients that benefit from having a sensor. And it may be that a sensor helps guide the frequency of standard fingerstick blood sugar tests. You know, that's one piece of technology that's getting data in. And really one of the barriers there is getting the data into the EMR without having to have somebody manually put it in, that enters an opportunity for an error. And the technology's there, these systems can communicate with electronic medical record, and those are just being rolled out.

Joseph Aloi  12:37

Once you have that in place, you can see a situation where it's very easy on the dosing side insulin dose calculators, Glucommander is one, glucose stabilizers and other endo tools and other I've done most of my research and work with Glucommander. But they can take the data from the patient in the EMR, and very safely give dosing recommendations for IV insulin with much less hyperglycemia and much more precision, then our standard Order set. That's a lot of research that I've done and others that have consistently shown that and I think we're at a meet I was at a meeting. The last time I was in a face to face meeting at the ADA and the conversation was because these electronic dosing systems do a better job should they become standard of care. And I think that also is on the horizon. And if you have those two coupled together, you can really seamlessly manage a patient with less interventions, fewer finger sticks, fewer episodes of waking a patient up to check their blood sugar. Fewer hopefully, this is a potential episodes of hypoglycemia, which are dangerous, potentially life threatening, drive up hospital costs.

Joseph Aloi  14:02

So I think I see a world for inpatient glucose management where sensors will be used more and electronic dosing calculators for insulin prescriptions, such as Glucommander will be used much more frequently in hospital systems, we've got a large body of studies and evidence that demonstrate this is a safer cost effective, better quality of care for patients. So that's one example of how I see technology coming in.

Joseph Aloi  14:38

The other thing, which is a maybe because I think there's less known as patients on the outside are being managed with what we call hybrid closed loop pumps hybrid because they're not fully closed loop. But we have sensors that communicate with insulin pumps, that This example I just gave in the outpatient arena where it's adjusting the insulin delivered by the insulin pump based on the glucose sensor, and glucose result. And the patient's rapidly dropping or hitting a threshold of a low blood sugar suspending the insulin.

Joseph Aloi  15:20

I think there for many, many patients, this is a huge add to their quality of life. And we're just collecting data now on do these patients have less cost of care associated with this because there is a little bit of initial investment when you pay for these pump sensor combinations. But when you look at devices, I'm not a cardiologist, I really don't know what a pacemaker costs. But, you know, pacemakers there you need it, or you're not going to have a regular rhythm or adequate heartbeat to perfuse and have good blood pressure. So it's a little more critical, but not quite comparing apples, apples, but the cost of a pump over and seven grand approximately, that's got a four year warranty. I know some of the ambulatory defibrillators are $50,000. I mean, I'm not sure what the right economics are, but certainly is a big improvement in quality of life when you have these systems that can manage glucose better than we used to with less intrusiveness. Although you do have that be connected to a pump. And the sensors are very small about the size of a 50 cent piece to a quarter and last 10 to 14 days for patients. So it's a simple change. I've worn them all they're comfortable. So I think those two things coupled together, both on the outpatient and inpatient can help patients make better decisions.

Joseph Aloi  16:52

And the last thing I'll say on that I don't want to forget to mention, there's a whole cadre of apps that are available to give patients advice on how to dose insulin. And it's almost Orwellian in the sense that if you connect all these through your smartphone, if you begin to think about it, we're now able to know where you are. So we know if you're in a restaurant, or if you're in a bar, or if you're at the gym, we know how many steps you've been doing, what your typical pattern is, we know how much sleep you got the last night, if you're putting in your meals and carbs you're eating we know how much. And so we're much better through some of these algorithms to be able to estimate how much insulin you need for a given meal because it's going to be different. If you're at the Ponderosa steakhouse, than if you're home in the backyard. grilling, maybe for the same steak you may be eating interfere vegan may be different if you're at Starbucks getting a soy latte, on a Wednesday, because you exercise on Tuesdays and Thursdays. But that type of clarity for data is happening in real time. And it really can make a quite a bit of difference in the dosing of insulin. So I think it's an exciting time for technology. And I wish I could have simpler options for patients. But at least now we have options that for many patients can sort of decrease the disease burden of trying to manage blood sugar's 24/7/365 days a year.

Brian Zimmerman  18:33

And I think that's sort of that that level of patient engagement and at home care and things like that, I think, are just becoming more and more prominent and important. And it's easy to think about the impact on people's quality of life tools like that can have So Dr. Aloi, thanks for laying all that out. And thanks for taking the time to speak with me today.

Joseph Aloi  18:51

Absolutely, I was really a pleasure talking with you, Brian.

Brian Zimmerman  18:54

Excellent. I'd also like to thank lights, as well for sponsoring this episode. Listeners. You can tune in to more podcasts from Becker's healthcare by visiting our podcast page at Becker's hospital