Many hospital providers not familiar with policies, use of diabetes technology
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Most health care providers working in hospitals said glycemic control is important to monitor in a hospital setting, but many do not know their institution’s policies regarding the use of diabetes technology, according to survey findings.
“Our study is the first to investigate the attitudes and practices of inpatient-licensed independent practitioners in the United States related to newer diabetes technologies,” M. Cecilia Lansang, MD, MPH, professor of medicine at the Endocrinology and Metabolism Institute at Cleveland Clinic Foundation, and colleagues wrote in a study published in Diabetes Technology & Therapeutics. “We have shown that most inpatient providers value glycemic control and use of insulin pumps; however, many reported limited knowledge of continuous subcutaneous insulin infusion and continuous glucose monitoring devices for optimal use to guide clinical care in the inpatient setting.”
Researchers conducted a web-based anonymous questionnaire from September to December 2020 to collect data regarding insulin pump and CGM use in hospitals. The questionnaire was designed to assess attitudes, behaviors and barriers perceived by providers and gather feedback on their familiarity with their institution’s policies. Years of experience, provider type, practice setting and volume of patients using diabetes technology were also collected. The questionnaire was sent to hospitalists, primary care providers and advanced practice providers with inpatient responsibilities at Cleveland Clinic, University of Chicago, Emory University and Vanderbilt University.
The questionnaire was sent to 500 providers, of whom 128 chose to participate. Of the cohort, 76% were day hospitalists, 67.5% said they worked at an academic medical center and 55% had 5 or more years of clinical practice.
Of the respondents, 96.1% said treating hyperglycemia in noncritically ill patients was either important or very important, and 93% said it was important or very important to continue continuous subcutaneous insulin infusion if no contraindication to continue the device existed.
Most (69%) of respondents said their institution had a policy for insulin pump use in the hospital. Of those whose institutions had a policy, 82% said they were somewhat or very familiar with the policy. For CGM, only 28% of the respondent’s institutions had a policy. Of providers whose institutions had a CGM policy, 62% said they were aware of the policy.
After discontinuing use of an insulin pump, 61% said they felt confident managing a patient’s diabetes. About half of respondents said they do not review insulin pump settings when admitting a patient. Of those who did review settings, 50% said they felt confident reviewing settings to guide further therapy. The most common reason reported for discontinuing insulin pump use was the patient’s mental state and impaired level of consciousness, followed by diabetic ketoacidosis and the patient’s inability to demonstrate appropriate insulin pump use.
Of the respondents, 69% said they consult their hospital’s endocrinology service for patients with an insulin pump, and 96% said they would continue continuous subcutaneous insulin infusion if there was no contraindication of doing so. When an insulin pump is discontinued, 58% said they prefer to do discontinuation through the pump interface rather than physically removing the pump.
Of the cohort, 52.8% said they cared for at least one person with a CGM in the 6 months prior to the questionnaire. Of those with exposure to CGM, 43.8% said they reviewed data from the device to guide therapy.
The researchers said more educational programs and better collaboration between inpatient providers and endocrinologists are needed to optimize use of diabetes technology in hospitals.
“Inpatient diabetes management has many stakeholders including patients, nurses and providers,” the researchers wrote. “Collaboration between all stakeholders involved will not only foster a safe environment for use of technologies, but also increase patient satisfaction and hopefully improve inpatient glycemic control.”
Perspective
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The unfamiliarity with diabetes technology, such as continuous subcutaneous insulin infusion and CGM, by non-endocrinologists in the inpatient setting has always been a barrier for patients to continue its use during hospitalization. Additionally, the rapid increase in utilization of continuous subcutaneous insulin infusion and especially CGM in the ambulatory setting during this pandemic has created an even wider gap in care for patients when hospitalized.
As the authors mentioned, guidelines from ADA, AACE and Endocrine Society all favor continuing the use of this technology when clinically appropriate and with hospital policies and protocols in place. However, this study highlights the many patient and practitioner limitations in the real world. Only two-thirds of inpatient practitioners are even aware of their hospital policies and protocols, but even more worrisome, the most common barrier was a lack of knowledge of continuous subcutaneous insulin infusion by both practitioners and nursing staff. CGM had an even poorer understanding of policy and clinical integration. Furthermore, we do not yet have a definitive approval by the FDA for these devices in the hospital setting, which makes the existing policies and practices subject to litigation.
As diabetes technology becomes more integral and routine in outpatient management, focus on this transition to inpatient care is imperative. This will require more research on its applicability for hospitalized patients, multidisciplinary education for all inpatient clinicians and, most importantly, detailed yet practical clinical guidelines that can easily be implemented.
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