Editorials
Using COPD Guidelines to Improve Patient Care
The worldwide chronic obstructive pulmonary disease (COPD) epidemic affects nearly 600 million people and accounts for more than 2.2 million deaths each year.1 Airflow obstruction makes COPD an even greater health burden because it independently contributes to the morbidity and mortality of coexisting chronic conditions, such as ischemic heart disease.2 Not surprisingly, more than 15 professional societies have published clinical practice guidelines about COPD during the past decade 3; however, the content and format of these guidelines are variable, and some experts say that to improve patient care, these efforts must be better coordinated.4,5
All COPD guidelines aim to improve health care processes and outcomes, decrease practice variation, and optimize resources.6 Although effective guidelines are developed systematically to be used easily in busy practices and to ensure scientifically valid outcomes, guidelines alone cannot improve patient care. Physicians must be committed to guideline dissemination and implementation for patient outcomes to improve.
The three-part mission of COPD guidelines includes systematic development, dissemination, and implementation. However, until recently, most COPD guideline developers have created hard-to-adopt, non-explicit recommendations using informal consensus methods or expert opinion.4,5 Most have only disseminated their guidelines through publication in subspecialty journals rather than reaching frontline physicians through multiple media and forums. And most guideline developers have not created effective implementation strategies. Consequently, little evidence has shown that COPD guidelines have affected health care processes or improved respiratory health.4
The future, however, appears promising. COPD has increasingly been recognized as an enormous health burden worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a collaboration of the World Health Organization, National Institutes of Health, and the National Heart, Lung, and Blood Institute, was formed as an organized international alliance aimed at creating an evidence-based set of practice parameters.7 The GOLD guideline developers update their recommendations regularly using systematic reviews of the literature and grading of the evidence. Also, the GOLD developers have designed dissemination and implementation strategies for their guideline efforts. Recent joint COPD guidelines from the European Respiratory Society and American Thoracic Society are in concordance with the GOLD recommendations; they are provided in Web-based format with patient education materials to promote dissemination and implementation.8 The British Thoracic Society COPD guidelines use evidence-based techniques and correspond well with GOLD guidelines.9 And, as demonstrated by Dewar and Curry's review of the diagnosis of COPD in this issue of American Family Physician,10 experts in primary care have joined the international effort to disseminate a congruent set of international evidence-based recommendations to primary care physicians.
COPD guidelines are evolving toward a more robust and effective future because of well-coordinated worldwide efforts to standardize recommendations and improve implementation strategies. Family physicians will remain on the leading edge of practice improvement efforts, because 70 percent of patients with COPD seek care from primary care physicians rather than pulmonary specialists. How well these patients do in the future depends on how effectively physicians can incorporate evidence-based COPD guidelines into their everyday clinical practices.
The Author
John E. Heffner, M.D., is professor and executive medical director at the Medical University of South Carolina, Charleston.
Address correspondence to John E. Heffner, M.D., 169 Ashley Ave., P.O. Box 250332, Charleston, SC 29425 (e-mail: heffnerj@musc.edu). Reprints are not available from the author.
REFERENCES
1. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet 1997;349:1498-504.
2. Sin DD, Man SF. Why are patients with chronic obstructive pulmonary disease at increased risk of cardiovascular diseases? The potential role of systemic inflammation in chronic obstructive pulmonary disease. Circulation 2003;107:1514-9.
3. Heffner JE. Chronic obstructive pulmonary disease: on an exponential curve of progress. Respir Care 2002; 47:586-607.
4. Heffner JE, Ellis R. The guideline approach to chronic obstructive pulmonary disease: how effective? Respir Care 2003;48:1257-66.
5. Lacasse Y, Ferreira I, Brooks D, Newman T, Goldstein RS. Critical appraisal of clinical practice guidelines targeting chronic obstructive pulmonary disease. Arch Intern Med 2001;161:69-74.
6. Audet AM, Greenfield S, Field M. Medical practice guidelines: current activities and future directions. Ann Intern Med 1990;113:709-14.
7. Fabbri LM, Hurd SS, for the GOLD Scientific Committee. Global Strategy for the diagnosis, management and prevention of COPD: 2003 update. Eur Respir J 2003;22:1-2.
8. American Thoracic Society. Standards for the diagnosis and management of patients with COPD. Accessed online July 18, 2005, at http://www-test.thoracic.org/copd/.
9. National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004;59(suppl 1):S1-232.
10. Dewar M, Curry RW Jr. Chronic obstructive pulmonary disease: diagnostic considerations. Am Fam Physician 2006;73:669-76, 677-8.
New Standards to Reduce Morbidity and Mortality in Hospitalized Patients with Diabetes
Diabetes has reached epidemic proportions in the United States. This is true whether patients are outpatients or inpatients; diabetes is the fourth most common comorbid condition complicating all hospital discharges. In 1997, diabetes was present in 9.5 percent of all patients discharged from hospitals and in 29 percent of patients undergoing cardiac surgery.1 Diabetes is associated with a two- to four-fold increase in hospitalization rates; its presence increases the length of hospital stays by one to three days, depending on the admission diagnosis. In-hospital hyperglycemia is an important marker of poor clinical outcomes and mortality in patients with or without diabetes.2
Although several organizations have issued guidelines for outpatient management of diabetes, no guidelines have been formulated for inpatient management. The American College of Endocrinology, in collaboration with several other organizations, has developed a consensus statement on inpatient diabetes and metabolic control.3 Because so many groups are involved in the care of hospitalized patients who may experience hyperglycemia, a multidisciplinary group was formed to develop a single set of standards and guidelines; the recommendations were cosponsored by the American Association of Diabetes Educators, the American Diabetes Association, the American Heart Association, the American Society of Anesthesiologists, the Society of Critical Care Medicine, the Society of Hospital Medicine, the Society of Thoracic Surgeons, the Endocrine Society, and the American College of Cardiology. The rationale for developing guidelines to achieve tight glycemic control in the hospital was based on increasing evidence that metabolic regulation of hyperglycemia translates into improved outcomes in patients with diabetes and in those who develop hyperglycemia in the hospital (see accompanying table4-10).
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Outcomes Associated with Hyperglycemia and Aggressive Insulin Therapy in Hospitalized Patients |
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Hyperglycemia Complications of MI4 Complications of stroke5 Complications of vascular and cardiac surgery6 Mortality in critically ill patients7 Mortality after coronary bypass surgery Aggressive insulin therapy Improved cardiac surgery outcomes8; mortality risk reductions of 50 percent or greater have been observed in patients treated with insulin infusions for the first three postoperative days. Improved ICU outcomes8-10 (e.g., 34 percent reduction in hospital mortality rates, 46 percent decrease in rates of sepsis, 41 percent decrease in rates of acute renal failure, 50 percent reduction in transfusions, 44 percent reduction in critical-illness polyneuropathy)9 Improved post-MI outcomes4 (e.g., 28 percent improvement in long-term survival rates in diabetic patients with acute MI) Reductions in infection rates, intubation times, length of hospital stays, and cost |
| MI = myocardial infarction; ICU = intensive care unit. Information from references 4 through 10. |
The consensus panel reviewed research with the original investigators to formulate standards for diabetes management in the hospital and to suggest techniques by which these goals and targets may be achieved. The data clearly show that all patients, especially those previously undiagnosed with diabetes, benefit from intensive management of hyperglycemia with insulin. The panel concluded that patients in intensive care units should have a target glycemic level of 110 mg per dL (6.1 mmol per L) and that medical and surgical patients should have a target preprandial level of 110 mg per dL and a maximal level of 180 mg per dL (10.0 mmol per L).
Insulin, whether administered intravenously or subcutaneously, was determined to be the primary means of effective glycemic control in the hospital setting. The use of standardized protocols for continuous intravenous insulin therapy is associated with improved glycemic control and low rates of hypoglycemia; the use of sliding scales is discouraged.
The next great challenge will be implementation of these standards. Hospital systems will have to change to achieve the goals defined above. Hospital- and ward-wide protocols for administration and monitoring of blood glucose levels and insulin infusions will be needed, as will protocols for risk management for hypoglycemia. Furthermore, a broad base of medical and surgical specialists must participate if we are to be successful in reducing diabetic inpatient mortality and morbidity rates; greater integration of care across units and the support of nursing and pharmacy staff will be needed. Clearly, there is a role for the family physician in the implementation and coordination of these guidelines.
The occurrence of significant hyperglycemia in the hospital will require close follow-up after discharge. In patients with previously diagnosed diabetes and an elevated A1C level, the preadmission diabetes care plan requires revision. In patients without previously diagnosed diabetes, the differentiation between hospital-related hyperglycemia and undiagnosed diabetes requires follow-up testing (e.g., fasting blood glucose measurements, two-hour oral glucose tolerance tests) once patients are metabolically stable. Outpatient diabetes self-management training is critical to minimize the risk of future complications.
The Author
Alan J. Garber, M.D., Ph.D., is professor in the Departments of Medicine, Molecular and Cellular Biology, and Biochemistry and Molecular Biology at Baylor College of Medicine, Houston, Texas.
Address correspondence to Alan J. Garber, M.D., Ph.D., Baylor College of Medicine, Faculty Center, Suite 1000, 1709 Dryden Rd., BCM-620, Houston, TX 77030. Reprints are not available from the author.
REFERENCES
1. Elixhauser A. Hospitalization in the United States, 1997. Rockville, Md.: Agency for Healthcare Research and Quality, 2000. AHRQ publication 00-0031.
2. Garber AJ, Seidel J, Armbruster M. Current standards of care for inpatient glycemic management and metabolic control: is it time for definite standards and targets? Endocr Pract 2004;10(suppl 2):10-2.
3. American College of Endocrinology. American College of Endocrinology consensus statement on guidelines for glycemic control. Endocr Pract 2002;8(suppl 1):5-11. Accessed online January 20, 2006, at: http://www.aace.com/pub/positionstatements.
4. Malmberg K. Role of insulin-glucose infusion in outcomes after acute myocardial infarction: the diabetes and insulin-glucose infusion in acute myocardial infarction (DIGAMI) study. Endocr Pract 2004;10(suppl 2):13-6.
5. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001;32:2426-32.
6. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract 2004;10(suppl 2):21-33.
7. Krinsely JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 2003;78:1471-8.
8. Van der Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345: 1359-67.
9. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients [published correction appears in Mayo Clin Proc 2005;80:1101]. Mayo Clin Proc 2004;79:992-1000.
10. Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med 2004;164:2005-11.
| Copyright © 2006 by the American
Academy of Family Physicians. |
