View source for Standardized Glycemic Management with a Computerized Workflow and Decision Support System for Hospitalized Patients with Type 2 Diabetes on Different Wards

The following is a review of Neubauer et al.(2015) study on the management of glycemic standards using computerized workflow and decision support systems. <ref name="Neubauer et al. 2015"> Neubauer, K. M., Mader, J. K., Höll, B., Aberer, F., Donsa, K., Augustin, T., ... & Pieber, T. R. (2015). Standardized glycemic management with a computerized workflow and decision support system for hospitalized patients with type 2 diabetes on different wards. Diabetes technology & therapeutics, 17(10), 685-692. http://www.ncbi.nlm.nih.gov/pubmed/26355756 </ref>

== Introduction ==

[[CDS]] technology is an emerging field in health informatics which combines the critical thinking of men, and optimizes it with the aid of a computerized system to yield better funded and conclusions based on evidence based medicine.The implementation tools provided by this system have promising features for physicians and their teams to arrive to optimal conclusions in the patient health delivery system. Diabetes is a well known public health issue and its management represent a greater challenge in present years. Using a paper-based algorithm for basal bolus insulin therapy developed to improve the quality of glycemic control and hospital complications, Neubauer and her team adapted it into a [[MHealth#Clinical Decision Support (CDS)|moblie decision support system]] named GlucoTab® system.
 
== Methods ==

This study was an open, noncontrolled interventional study in hospitalized patients with Type 2 diabetes. The study was conducted on four general wards of a tertiary-care hospital: Endocrinology, Cardiology, Nephrology and Plastic Surgery. 99 hospitalized patients were recruited from 5/2013-12/2013.  

GlucoTab® system applied a daily dose of basal insulin, bolus insulin before each meal, and a correctional dose at bedtime to achieve fasting and premeal BG (Blood Glucose) values of less than 140 mg/dL. One-half of the total daily dose was administered as basal insulin once a day before lunch. The other half was administered as bolus insulin three times a day (45% of the total dose for breakfast bolus, 25% for lunch bolus, and 30% for dinner bolus).

* Daily dose: 0.5 units/kg 

In order to yield the results from the study the following procedures were conducted: 

* To test if the mean percentage of BG measurements in the target range 70–140 mg/dL were greater than the ones in the recent best-practice study with the criterion value of 42%, they applied a one-tailed one-sample t test. <ref name="Umpierrez et al. 2013"> Umpierrez GE, Smiley D, Hermayer K, et al.: Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care 2013;36:2169–2174 </ref>

* The wards were compared using the Kruskal–Wallis rank sum test for secondary outcome since patients were unequally distributed among the wards.

*Finally, a multiple regression model to predict the mean daily BG value over all study days, except study Day 1, was fitted to the data.

== Results ==  

* GlucoTab® system was highly accepted; Physicians adhered to the suggested total daily insulin doses in 97.5% of cases, and nurses' adherence rates with suggested bolus insulin doses and basal insulin doses were 96.5% and 96.7%

* The mean percentage of BG measurements in the target range 70–140 mg/dL was 50.2±22.2%; Higher than the criterion value of 42% derived from the recent best-practice study

* Twenty-eight mild and moderate adverse events and one serious adverse event occurred, nonetheless not a single one was attributed to the GlucoTab® system

* GlucoTab® system received positive feedback through a questionnaire from 59 of 65 physicians 
   
== Conclusion ==

The GlucoTab® system can be implemented in the clinical setting according to the results yield by the study. Factors such as preexisting home insulin therapy and the HbA1c values in addition to the type of hospital admission and the first total daily insulin dose can be pointed as the cause for the high BG mean values yielded during hospitalization. Inclusion criteria of the patients as them been non-controlled and open, represent a serious implication to asses the results as reliable.  

== Comments == 
GlucoTab® system allowed an efficient, safe, and friendly-user implementation of a standardized glycemic management system throughout the different wards of the hospital. Data in such study further only supports the claim that systems such as this can improve the health care delivery of diabetes with confidence of not expecting consequences due to their implementation. This study not only highlights the fact that if a CDS tool is implemented properly can have a positive impact in clinical outcomes but also become a powerful teaching tool for the physicians in training.

== Related Articles ==
*[[Benefits of Information Technology-Enabled Diabetes Management]]
*[[Impact of electronic health record clinical decision support on diabetes care: a randomized trial]]

== References ==
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[[Category:Reviews]]
[[Category:CDS]]
[[Category:MHealth]]