Zeller William P, DeGraff Rachel, Zeller William
J Clin Transl Endocrinol Case Rep. 2021 Mar;19:100078. doi: 10.1016/j.jecr.2021.100078. Epub 2021 Jan 27.
Our endocrinology practice needed to protect its highest-risk patients with type 1 diabetes (T1D) during the COVID-19 pandemic. To do so, we needed to identify these patients and develop a protocol to keep them out of the hospital (to limit risk of infection and conserve medical resources), and do so without in-person visits. So we used our peer-reviewed software, Diabetes Reporting, to identify 87 patients whose glucose management indicator (GMI) scores were over 9%. The GMI is a method for estimating the laboratory A1C using the patient's actual blood glucose measurements over the past 90 days. A GMI (or A1C) over 9% indicates a heightened risk of diabetic ketoacidosis (DKA) and, possibly, a slightly higher risk of severe hypoglycemia (SH), the two most common acute complications leading patients with T1D to be hospitalized. We contacted these 87 at-risk patients and enrolled them in a quality improvement project. This project consisted of additional online meetings with their doctors as well as weekly reports generated by Diabetes Reporting for three months, between March 28, 2020 and June 28, 2020. We hypothesized that this heightened communication would reduce the incidence of DKA and SH among the participants by reducing their GMI. As a comparison group, we used data from the T1D Exchange, which showed that, among patients with an A1C over 9%, 6.7% were hospitalized for DKA and 7% experienced SH leading to loss of consciousness in a three-month period. This led us to predict 6 incidences of DKA and 6 incidences of SH among our 87 participants during the three-month period. Instead, we saw 2 incidences of DKA and 1 incidence of SH. Moreover, the mean GMI of our participants dropped from 9.91% to 9.25%, a clinically-significant 0.66% improvement, which supports the conclusion that our protocol helped avoid acute complications among a cohort of at-risk patients with T1D by improving glycemic control during a time when we were limited to largely online care. This telemedicine protocol merits further research for its potential to improve and lower costs of care for patients with T1D, particularly for those at higher risk for acute complications.
在新冠疫情期间，我们的内分泌科需要保护1型糖尿病（T1D）的高危患者。为此，我们需要识别出这些患者，并制定一个方案让他们避免住院（以降低感染风险并节省医疗资源），且无需面对面就诊。于是，我们使用了经过同行评审的软件“糖尿病报告”，识别出87名血糖管理指标（GMI）得分超过9%的患者。GMI是一种利用患者过去90天的实际血糖测量值来估算糖化血红蛋白（A1C）的方法。GMI（或A1C）超过9%表明糖尿病酮症酸中毒（DKA）风险增加，可能还有严重低血糖（SH）风险略有升高，这是导致T1D患者住院的两种最常见急性并发症。我们联系了这87名高危患者，并让他们参与一个质量改进项目。该项目包括与他们的医生进行更多线上会诊，以及在2020年3月28日至2020年6月28日的三个月期间由“糖尿病报告”生成的每周报告。我们假设这种加强沟通将通过降低GMI来降低参与者中DKA和SH的发生率。作为对照组，我们使用了T1D交换平台的数据，该数据显示，在糖化血红蛋白超过9%的患者中，6.7%因DKA住院，7%在三个月内发生SH导致意识丧失。这使我们预测在三个月期间，我们的87名参与者中会有6例DKA和6例SH。然而，我们只看到了2例DKA和1例SH。此外，参与者的平均GMI从9.91%降至9.25%，有临床意义的0.66%的改善，这支持了我们的方案通过在主要限于线上护理的时期改善血糖控制，帮助高危T1D患者群体避免急性并发症的结论。这种远程医疗方案因其改善T1D患者护理并降低护理成本的潜力，值得进一步研究，特别是对于急性并发症风险较高的患者。
