Published in the May 2011 issue of Today’s Hospitalist
FOR HOSPITALISTS, the first hours after admitting a stroke patient are consumed with managing stroke-related issues. But it’s also the ideal opportunity to identify an undiagnosed comorbidity that could severely affect patients’ near-term recovery and long-term prognosis: diabetes.
Last year, stroke specialists at the Ronald Reagan UCLA Medical Center began a quality improvement initiative to ensure routine HbA1c testing and start treatment in patients who meet the diagnostic threshold for diabetes. The stroke team started the initiative after finding that 10% of patients being admitted for stroke or transient ischemic attack (TIA) had unrecognized diabetes.
"Ten percent might not sound like a lot," says neurologist and stroke expert Bruce Ovbiagele, MD, MSc, who devised the initiative, "but when you realize that UCLA’s population is mostly upper middle class, well-informed and insured, it’s a considerable number." He notes that at UCLA’s Olive View campus in the San Fernando Valley, which has a more diverse patient population, nearly 30% of stroke patients had undiagnosed diabetes or prediabetes.
"That figure is probably closer to what hospitalists in community hospitals might find," says Dr. Ovbiagele, who now practices at University of California, San Diego (UCSD), and will be implementing the initiative at UCSD.
Getting screening off the ground
The primary objective of the year-old Swift Evaluation and Early Treatment to Favorably Impact Inconspicuous Glucose Excess (dubbed SWEET-FIX) program is to systemically screen all stroke patients for diabetes using the HbA1c. The program starts drug treatment and lifestyle and dietary counseling before discharge. And it ensures that patients diagnosed with diabetes or prediabetes receive a formal referral for follow-up.
The program initiates medications “hypoglycemic agents, antihypertensives, and renin-angiotensin system and lipid system modulators “as warranted by HbA1c levels and other diabetes risk factors. (Researchers described the SWEET-FIX program in a December 2010 article in Critical Pathways in Cardiology.)
But initiating all those components depends on a physician making the diagnosis. "Everybody with a stroke or TIA gets screened," says Dr. Ovbiagele, a professor of neurosciences. "It’s no longer just a checkbox on the order sheet, it’s a bullet. By having the admitting physician sign the orders, the HbA1c test will be done."
Dr. Ovbiagele suspects that this super-aggressive screening approach goes beyond what national stroke guidelines call for and what happens in many hospitals. He adds that stroke patients are particularly at risk for undetected or untreated diabetes if neurologists, not hospitalists, manage their care.
"Neurologists are not as comfortable treating diabetes as hospitalists and PCPs," he says, nor are neurologists as aware of diabetes as a risk factor. When neurologists manage stroke patients, Dr. Ovbiagele points out, they often fail to even have a conversation about managing diabetes, let alone start treatment or activate a patient-education team.
In fact, he explains, one hitch in getting the program off the ground at UCLA was educating non-hospitalist clinical personnel. Many neurologists and neuroscience nurses had little or no experience treating or managing diabetes. They needed formal training on various medications, contraindications and side effects.
"It was challenging at first to convince some staff and attendings of the value of this program," he says. "But given the obesity epidemic, it was important to put screening and management mechanisms in place throughout the hospital." Nurses also were trained to provide initial diabetes counseling.
High risk for poor outcomes
Making the diagnosis and starting treatment in the hospital are important, Dr. Ovbiagele notes, because stroke patients with prediabetes or diabetes are at high risk for poor stroke outcomes or for future CVAs or cardiac events.
"We’re not sure exactly why," he says, "but patients with high blood sugar are less likely to recover from stroke or they recover more slowly." Patients with uncontrolled glucose are also at higher risk for stroke mortality.
Although most admission order sets call for serum glucose testing as part of a basic metabolic panel, patients typically don’t undergo HbA1c testing unless mean plasma glucose levels exceed 126. That’s because clinicians often assume that hyperglycemia is stress-related.
According to Dr. Ovbiagele, HbA1c testing has greater diagnostic value because it indicates how well blood sugar has been controlled in the preceding three months. The HbA1c test is also more expensive and more time-consuming for nurses because it involves a full blood draw vs. a drop of blood. But he notes that fears that the program would increase nurse or physician workload have proved to be unfounded.
Once patients are diagnosed with diabetes or prediabetes, they begin treatment. Oral metformin (500 mg twice daily) is the agent of choice for patients with mildly abnormal levels who can tolerate oral medications; those with dangerously elevated HbA1c “8.5% and higher “receive injectable insulin. Patients with prediabetes and one or more additional diabetes risk factors are started on low-dose metformin.
All patients with diabetes or prediabetes receive lifestyle counseling from nurses and registered dieticians. To reduce the burden of complying with the SWEET-FIX protocol, clinical staff use admission order sheets, pocket cards detailing the program goals and treatment algorithm, and quick-reference cards listing diabetes drugs, doses and side effects.
Don’t skip lifestyle counseling
For community hospitalists who might not have UCLA’s personnel resources, Dr. Ovbiagele urges them to make sure that patients still receive lifestyle and diet counseling. He sees many patients with confirmed diabetes who are already on insulin but don’t know anything about the lifestyle changes they need to make.
"Having a nutritionist on board to answer questions about diet is extremely important," he says.
Although there is no hard evidence that identifying and treating diabetes in previously undiagnosed stroke patients will improve their outcomes, common sense suggests intermediate and long-term benefits, Dr. Ovbiagele maintains.
"Prompt diagnosis and early management of diabetes may reduce the actual occurrence of future stroke, myocardial infarction or other diabetes complications," he says. Lowering blood sugar could also improve outcomes in the event the patient suffers an MI or recurrent stroke. The potential length-of-stay benefit would come from reducing hyperglycemia in the hospital and possibly reducing unnecessary readmissions.
The SWEET-FIX team won’t be compiling data until next year, when team members will look at patients’ target biomarkers (HbA1c levels, lipids and cholesterol) at three and 12 months. But anecdotal reports so far, Dr. Ovbiagele points out, have convinced him of the program’s effectiveness.
Bonnie Darves is a freelance health care writer based in Seattle.