Endocr Pract. 2019 Aug;25(8):836-845. doi: 10.4158/EP-2018-0498. Epub 2019 May 9.
Most acute-care hospitals have transitioned from sliding-scale to basal-bolus insulin therapy to manage hyperglycemia during hospitalization, but there is limited scientific evidence demonstrating better short-term clinical outcomes using the latter approach. The present study sought to determine if using basal-bolus insulin therapy favorably affects these outcomes in noncritical care settings and, if so, whether the magnitude of benefit differs in patients with known versus newly diagnosed type 2 diabetes. This natural experiment compared outcomes in 10,120 non-critically ill adults with type 2 diabetes admitted to an academic teaching hospital before and after hospital-wide implementation of a basal-bolus insulin therapy protocol. A group of 30,271 inpatients without diabetes (type 1 or 2) served as controls. Binomial models were used to compare percentages of patients with type 2 diabetes who were transferred to intensive care, experienced complications, or died in the hospital before and after implementation of the protocol, controlling for changes in the control group. The analysis also evaluated before-after changes in length of stay and glucometric indicators. Implementation of basal-bolus therapy did not reduce intensive care use (the primary outcome), complications, mortality, or median length of stay, except in patients with newly diagnosed diabetes (n = 234), who experienced a statistically significant decline in the incidence of complications (<.01). The absence of effect in previously diagnosed patients was observed in spite of a 32% decline (from 3.7% to 2.5%) in the proportion of inpatient days with hypoglycemia <70 mg/dL (<.01) and a 16% decline (from 13.5% to 11.3%) in the proportion of days with hyperglycemia >300 mg/dL (<.01). Despite achieving significant reductions in both hyperglycemia and hypoglycemia, use of basal-bolus insulin therapy to manage hyperglycemia in non-critically ill hospitalized patients did not improve short-term clinical outcomes, except in the small minority of patients with newly diagnosed diabetes. The optimal management of hyperglycemia for improving these outcomes has yet to be determined. = International Classification of Diseases-Ninth Revision.
大多数急症护理医院已经从调整剂量胰岛素方案过渡到基础-餐时胰岛素方案，以在住院期间管理高血糖，但目前仅有有限的科学证据表明后一种方法可带来更好的短期临床结局。本研究旨在确定在非重症监护环境中使用基础-餐时胰岛素方案是否会对这些结局产生有利影响，以及在已知或新诊断的 2 型糖尿病患者中，获益的程度是否存在差异。 本自然实验比较了在一家学术教学医院实施全院范围的基础-餐时胰岛素方案前后，10120 例非危重症 2 型糖尿病成年患者的结局。将 30271 例无糖尿病（1 型或 2 型）住院患者作为对照组。采用二项式模型比较方案实施前后 2 型糖尿病患者转入重症监护病房、发生并发症或死亡的比例，同时控制对照组的变化。分析还评估了住院时间和血糖指标的前后变化。 基础-餐时治疗方案的实施并未降低重症监护的使用（主要结局）、并发症、死亡率或中位住院时间，除了新诊断为糖尿病的患者（n = 234），他们的并发症发生率显著下降（<.01）。尽管低血糖<70mg/dL（<.01）的住院天数比例下降了 32%（从 3.7%降至 2.5%），血糖>300mg/dL（<.01）的天数比例下降了 16%（从 13.5%降至 11.3%），但先前诊断的患者中并未观察到这种效果。 尽管实现了高血糖和低血糖的显著降低，但在非危重症住院患者中使用基础-餐时胰岛素方案来管理高血糖并不能改善短期临床结局，除了新诊断为糖尿病的小部分患者。为改善这些结局而优化高血糖的管理方法仍有待确定。 = 国际疾病分类第九版。
