实施简单算法以改善糖尿病合并急性冠状动脉综合征患者的血糖和血脂管理。
Implementing simple algorithms to improve glucose and lipid management in people with diabetes and acute coronary syndrome.
机构信息
Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia.
Department of Cardiology, Fiona Stanley Hospital, Murdoch, WA, Australia.
出版信息
Diabet Med. 2019 Dec;36(12):1643-1651. doi: 10.1111/dme.14095. Epub 2019 Aug 9.
AIM
Diabetes mellitus is associated with increased risk of adverse outcomes following acute coronary syndrome. Translating evidence-based recommendations into practice is necessary to improve outcomes. We evaluated whether implementing algorithms to guide inpatient care improved glycaemic control, and increased use of sodium-glucose co-transporter 2 (SGLT2) inhibitors and lipid-lowering medication in a tertiary cardiac unit.
METHOD
A 3-month audit (phase 1) was conducted to evaluate hyperglycaemia and dyslipidaemia management, and medication prescriptions. Consecutive people with diabetes admitted for acute coronary syndrome were prospectively identified. Target blood glucose level was defined as 5-10 mmol/l. A multidisciplinary committee designed and implemented decision-support algorithms plus education. A 3-month post-implementation audit (phase 2) was conducted.
RESULTS
There were 104 people in phase 1 and 101 in phase 2, with similar characteristics [HbA 64 ± 20 mmol/mol vs. 61 ± 21 mmol/mol (8.0 ± 1.8% vs. 7.8 ± 1.9%]. Post implementation, the incidence of blood glucose levels > 10 mmol/l was lower [phase 1: 46.4% vs. phase 2: 31.8%, rate ratio (RR) = 0.77, 95% confidence intervals (CI) 0.60-0.98; P = 0.031], without a difference in blood glucose levels < 5mmol/l (phase 1: 4.9% vs. phase 2: 4.5%, RR = 1.20, 95% CI 0.70-2.08; P = 0.506). SGLT2 inhibitor prescriptions increased significantly (baseline to discharge: 12.5% to 15.4% vs. 7.9% to 24.8%; P = 0.007) but high-intensity statin prescriptions did not (baseline to discharge: 35.6% to 72.1% vs. 40.6% to 85.1%; P = 0.074). Prescription rates of non-statin lipid-lowering medications were not significantly increased.
CONCLUSIONS
Implementing decision-support algorithms was associated with improved inpatient glycaemic control and increased use of cardioprotective therapies at discharge in people with diabetes and acute coronary syndrome.
目的
糖尿病与急性冠状动脉综合征后不良结局风险增加相关。将循证建议转化为实践是改善结局所必需的。我们评估了在三级心脏中心实施指导住院治疗的算法是否改善了血糖控制，并增加了钠-葡萄糖共转运蛋白 2 (SGLT2)抑制剂和降脂药物的使用。
方法
进行了为期 3 个月的审计（第 1 阶段），以评估高血糖和血脂异常的管理以及药物处方。前瞻性地确定了因急性冠状动脉综合征住院的连续糖尿病患者。目标血糖水平定义为 5-10mmol/l。一个多学科委员会设计并实施了决策支持算法和教育。进行了 3 个月的实施后审计（第 2 阶段）。
结果
第 1 阶段有 104 人，第 2 阶段有 101 人，特征相似[HbA64±20mmol/mol vs.61±21mmol/mol（8.0±1.8% vs.7.8±1.9%）]。实施后，血糖水平>10mmol/l 的发生率较低[第 1 阶段：46.4%vs.第 2 阶段：31.8%，率比（RR）=0.77，95%置信区间（CI）0.60-0.98；P=0.031]，而血糖水平<5mmol/l 的发生率没有差异（第 1 阶段：4.9%vs.第 2 阶段：4.5%，RR=1.20，95%CI 0.70-2.08；P=0.506）。SGLT2 抑制剂的处方显著增加（基线至出院：12.5%至 15.4%vs.7.9%至 24.8%；P=0.007），但高强度他汀类药物的处方没有增加（基线至出院：35.6%至 72.1%vs.40.6%至 85.1%；P=0.074）。非他汀类降脂药物的处方率没有显著增加。
结论
在患有糖尿病和急性冠状动脉综合征的患者中，实施决策支持算法与改善住院血糖控制和增加出院时的心脏保护治疗有关。
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