Associations between COVID-19 therapies and inpatient gastrointestinal bleeding: A multisite retrospective study.

Little data is available regarding the incidence of gastrointestinal bleeding in adults hospitalized with COVID-19 infection and the influence of patient comorbidities and demographics, COVID-19 therapies, and typical medications used. In this retrospective study, we utilized the National COVID Cohort Collaborative to investigate the primary outcome of the development of gastrointestinal bleeding in 512 467 hospitalized US adults (age >18 years) within 14 days of a COVID-19 infection and the influence of demographics, comorbidities, and selected medications. Gastrointestinal bleeding developed in 0.44% of patients hospitalized with COVID-19. Comorbidities associated with gastrointestinal bleeding include peptic ulcer disease (adjusted odds ratio [aOR] 10.2), obesity (aOR 1.27), chronic kidney disease (aOR 1.20), and tobacco use disorder (aOR 1.28). Lower risk of gastrointestinal bleeding was seen among women (aOR 0.76), Latinx (aOR 0.85), and vaccinated patients (aOR 0.74). Dexamethasone alone or with remdesivir was associated with lower risk of gastrointestinal bleeding (aOR 0.69 and aOR 0.83, respectively). Remdesivir monotherapy was associated with upper gastrointestinal bleeding (aOR 1.25). Proton pump inhibitors were more often prescribed in patients with gastrointestinal bleeding, likely representing treatment for gastrointestinal bleeding rather than a risk factor for its development. In adult patients hospitalized with COVID-19, the use of dexamethasone alone or in combination with remdesivir is negatively associated with gastrointestinal bleeding. Remdesivir monotherapy is associated with increased risk of upper gastrointestinal bleeding.

IMPACT OF STRUCTURED INSULIN ORDER SETS ON INPATIENT HYPOGLYCEMIA AND GLYCEMIC CONTROL.

Objective: In hospitalized patients, glycemic excursions outside recommended glycemic targets have been associated with increased morbidity and mortality. Despite recommendations to avoid use of correctional insulin alone for managing hyperglycemia, this approach remains common. We performed a quality improvement project aimed at both reducing hypoglycemic events and promoting increased use of basal insulin by updating our insulin order sets to reflect clinical practice guideline recommendations. Methods: Brooke Army Medical Center correctional insulin order sets were modified to reflect higher treatment thresholds and targets, and a basal insulin order was added with a recommended weight-based starting dose. Pre- and postintervention analyses were performed. Patients were included if they were prescribed subcutaneous insulin during their hospital stay. The following outcomes were measured: (1) glucose levels, and (2) prescriptions for basal insulin. Results: A significant reduction in hypoglycemia events was noted following the intervention (glucose <70 mg/dL: 9.2% pre-intervention vs. 8.8% postintervention; glucose <55 mg/dL: 4.2% pre-intervention vs. 2.2% postintervention). When excluding patients that were ordered correctional insulin alone but did not receive a dose, an increase in basal insulin use was seen (50% pre-intervention vs. 61% postintervention). Rates and severity of hyperglycemia (glucose >180 mg/dL) remained unchanged. Conclusion: The alteration in insulin order set parameters resulted in a significant reduction in hypoglycemia without significant increases in hyperglycemia. Although basal insulin use increased, optimal dosing recommendations were not often utilized. Further interventions are necessary to reduce hyperglycemia. Abbreviations: CPOE = computerized provider order entry; EMR = electronic medical record; HbA1c = hemoglobin A1c; LOS = length of stay; QI = quality improvement; SSI = sliding scale insulin.

Preconception Counseling for Women With Diabetes.

"Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the efforts of a U.S. Airforce diabetes specialty clinic to improve the delivery of preconception counseling to women with diabetes who are of childbearing potential.

THE IMPACT OF GLP-1 RECEPTOR AGONISTS ON PATIENTS WITH DIABETES ON INSULIN THERAPY.

Objective: The clinical benefit of adding a glucagon-like peptide-1 receptor agonist (GLP-1RA) to basal-bolus or very high dose insulin regimens is unclear. This study investigated the impact of adding a GLP-1RA to a spectrum of insulin regimens (basal, basal-bolus, and U-500) to determine the impact on hemoglobin A1c (HbA1c), weight loss, and total daily insulin dose (TDD) over the course of 12 months. Methods: A retrospective chart review was conducted on 113 participants with type 2 diabetes mellitus using insulin therapy. Each participant's HbA1c, body weight, and TDD were recorded prior to initiation of GLP-1RA therapy and at the 3, 6, and 12-month time points while on combination therapy. Results: Across all participants, the HbA1c values decreased significantly from a baseline of 8.9 (74 mmol/mol) ± 0.14% to 8.2 (66 mmol/mol) ± 0.14% (P<.01) in the first 3 months, 8.0 (64 mmol/mol) ± 0.12% (P<.01) at 6 months, to 8.3 (67 mmol/mol) ± 0.14% (P<.01) at 12 months. There was no significant decrease in weight or TDD with the addition of a GLP-1RA overall or in different insulin groups. However, there was a clinically significant decrease in weight over the study duration. Conclusion: The results of this study suggest that adding a GLP-1RA to various insulin regimens may help to achieve glycemic goals while avoiding the less desirable side effects of weight gain and increasing insulin regimens. However, the expected weight loss and decrease in TDD may not be as sizable in the clinical setting. Abbreviations: DCOE = Diabetes Center of Excellence; DM = diabetes mellitus; GLP-1RA = glucagon-like peptide-1 receptor agonist; HbA1c = hemoglobin A1c; RCT = randomized controlled trial; TDD = total daily dose.

Is It Distress, Depression, or Both? Exploring Differences in the Diabetes Distress Scale and the Patient Health Questionnaire in a Diabetes Specialty Clinic.

IN BRIEF Patients (n = 314) completed the Patient Health Questionnaire and the Diabetes Distress Scale as part of standard care. Although most patients (70.4%) had no symptoms of depression or diabetes-related distress, 23.9% scored high on the distress questionnaire in at least one of its four domains. Regular screening for distress related to the demands of living with diabetes is crucial in identifying and preventing poor health outcomes associated with diabetes-related distress.

Patient Commitment and Its Relationship to A1C.

IN BRIEF This study examined the relationship between patient commitment and A1C. Patients completed the Altarum Consumer Engagement (ACE) measure. Multiple A1C values were extracted from medical records for 273 military beneficiaries. Effects were analyzed with generalized linear models. The ACE Commitment subscale was significantly inversely related to A1C trends. Low-commitment patients were more likely to have a high A1C. High-commitment patients were 16% more likely to have an A1C <7.0%; this likelihood increased to 65% over time. The ACE Commitment domain may be a useful clinical tool. Increasing patients' commitment to managing diabetes may improve their A1C over time.

Diabetes Center of Excellence Hypoglycemia Emergency Preparedness Project.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a successful effort to ensure that patients who are at risk for severe hypoglycemic events have a viable glucagon emergency plan in place.

EVALUATION OF TOTAL DAILY DOSE AND GLYCEMIC CONTROL FOR PATIENTS TAKING U-500 REGULAR INSULIN ADMITTED TO THE HOSPITAL.

OBJECTIVE: Patients using U-500 regular insulin are severely insulin resistant, requiring high doses of insulin. It has been observed that a patient's insulin requirements may dramatically decrease during hospitalization. This study sought to systematically investigate this phenomenon. METHODS: We performed a retrospective chart review of patients with U-500 insulin outpatient regimens who were admitted to the San Antonio Military Medical Center over a 5-year period. Each patient's outpatient total daily dose (TDD) of insulin was compared to the average inpatient TDD. The outpatient estimated average glucose (eAG) was calculated from the glycated hemoglobin (HbA1c) and compared to the average inpatient glucose. RESULTS: There were 27 patients with a total of 62 separate admissions. The average age was 64.4 years, with a mean body mass index of 38.9 kg/m2 and eAG of 203 mg/dL (HbA1c, 8.7%, 71.6 mmol/mol). All patients were converted from U-500 to U-100 upon admission. The average inpatient TDD of insulin was 91 units, versus 337 units as outpatients (P<.001). Overall, 89% of patients received ≤50% of their outpatient TDD. The average inpatient glucose was slightly higher than the outpatient eAG, 234 mg/dL versus 203 mg/dL (P = .003). CONCLUSION: U-500 insulin is prone to errors in the hospital setting, so conversion to U-100 insulin is a preferred option. Despite a significant reduction in insulin TDD, these patients had clinically similar glucose levels. Therefore, patients taking U-500 insulin as an outpatient can be converted to a U-100 basal-bolus regimen with at least a 50% reduction of their outpatient TDD. ABBREVIATIONS: BG = blood glucose eAG = estimated average glucose HbA1c = glycated hemoglobin NPO = nil per os SPSS = Statistical Package for the Social Sciences TDD = total daily dose.

Factors associated with diabetes-related distress: implications for diabetes self-management.

As 7.8% of the U.S. population is affected by diabetes, health care providers are tasked with providing resources to assist patients toward self-management. Psychosocial issues have an effect on diabetes self-care. Diabetes-related distress is associated with self-management and lower A1C. This cross-sectional study seeks to understand how demographic factors, psychological orientations, support, and diabetes management behaviors predict diabetes-related distress. This study uses data from 267 adults with Type 2 diabetes. The Diabetes Distress Scale (DDS) is a 17-item scale measuring diabetes-related distress including emotional distress, physician-related distress, regimen distress, and interpersonal distress. Hierarchical regression was conducted in four stages. The final model explains 48% of the variance in DDS. Significant factors related to lower DDS were older age, lower body mass index, higher self-efficacy, higher levels of health care provider support, and a healthy diet. Findings of this study help health care providers know where to focus to reduce diabetes-related distress. Health care provider support is significant in reducing DDS. Diabetes education may want to include strategies that increase self-efficacy and assist people with diabetes to obtain a healthy weight through a more healthful diet.

Listening campaigns: engaging clinicians to assess system factors contributing to burnout.

BACKGROUND: Even prior to the pandemic, many US physicians experienced burnout affecting patient care quality, safety and experience. Institutions often focus on personal resilience instead of system-level issues. Our leaders developed a novel process to identify and prioritise key system-related solutions and work to mitigate factors that negatively impact clinician well-being through a structured listening campaign. METHODS: The listening campaign consists of meeting with each clinician group leader, a group listening session, a follow-up meeting with the leader, a final report and a follow-up session. During the listening session, clinicians engage in open discussion about what is going well, complete individual reflection worksheets and identify one 'wish' to improve their professional satisfaction. Participants rate these wishes to assist with prioritisation. RESULTS: As of January 2020, over 200 clinicians participated in 20 listening sessions. One hundred and twenty-two participants completed a survey; 80% stated they benefited from participation and 83% would recommend it to others. CONCLUSION: Collecting feedback from clinicians on their experience provides guidance for leaders in prioritising initiatives and opportunities to connect clinicians to organisational resources. A listening campaign is a tool recommended for healthcare systems to elicit clinician perspectives and communicate efforts to address systemic factors.

Developing a Diabetes Discharge Order Set for Patients With Diabetes on Insulin.

BACKGROUND: Insulin, a high-risk medication, is prone to prescribing errors. Patients with diabetes experience higher hospitalization rates and extended hospital stays. Prescription errors, such as missing orders, inappropriate insulin type, missing instructions, and lack of appropriate intensification of insulin regimens are common issues. This project explored the use of system-based interventions and educational tools to minimize errors and improve the quality of insulin discharge regimens. METHODS: A needs assessment and baseline chart review were conducted before adapting a diabetes order set obtained from the University of California, San Diego. Subsequent beta testing and broader implementation were followed by repeat chart reviews to assess the impact. RESULTS: Providers strongly desired an insulin discharge order set, with 98% of those surveyed expressing this preference. Those who were high utilizers of the order set showed increased rates of ordering all supplies (55%), compared with pre-intervention rates (27%). However, no change was observed in the practice of intensifying insulin regimens in patients with uncontrolled diabetes upon discharge. DISCUSSION: Insulin prescribing is prone to error. A diabetes discharge order set may improve the percentage of patients who receive necessary insulin supplies at discharge and provide educational resources to encourage appropriate insulin regimens at hospital discharge.

Using Contact-Based Education to Reduce Diabetes-Related Stigma Among Medical Residents in a Military Health System.

INTRODUCTION: Healthcare provider-related stigma against patients with diabetes is associated with worse doctor-patient relationships and patient self-care. A previous feasibility study showed benefit in using a contact-based education approach to improve attitudes of medical students toward patients with diabetes. We hosted a panel of people who had personal experience with diabetes. The panel was attended by internal medicine residents in a military health system. We compared diabetes-related stigma among the residents before and after the panel. MATERIALS AND METHODS: Panel participants included a Black male active duty service member diagnosed with type 2 diabetes, a Black veteran with type 2 diabetes, and a White woman with two sons who have type 1 diabetes. During a 1 hour panel for medicine residents, these panelists were asked to discuss their personal experiences with diabetes, common misconceptions regarding diabetes, and what they wish healthcare providers understood about diabetes. The validated Diabetes Attitude Scale-3 (DAS-3) questionnaire, which assesses diabetes-related attitudes based on a five-point Likert scale (strongly agree = 5, strongly disagree = 1), was given to the trainees before and after the panel. The survey also collected demographic information and contained short-answer questions about personal experiences with diabetes and diabetes-related stigma. Survey responses were linked with identifier questions to preserve anonymity. RESULTS: Twelve participants completed both the pre- and post-panel survey. Seven were female (58%), 10 were White (83%), and eight were from suburban communities (67%). Mean scores improved for all five DAS-3 subscales scores, with the largest improvement in the Patient Autonomy subscale (4.12 to 4.4), followed by Psychosocial Impact of Diabetes Mellitus (4.34 to 4.56), Seriousness of Non-Insulin Dependent Diabetes Mellitus (4.27 to 4.44), Need for Special Training (4.52 to 4.68), and Value of Tight Control (4.07 to 4.10). CONCLUSIONS: Contact-based education can be considered as a tool for reducing diabetes-related stigma among medical trainees.

Creating Patient Context: Empathy and Attitudes Toward Diabetes Following Virtual Immersion.

BACKGROUND: Pandemic circumstances created challenges for doctor of physical therapy (DPT) students to understand social determinants of health (SDH) in clinical rotations. Instead of canceling clinical rotations, a virtual reality cinema (cine-VR) education series was implemented. The purpose of this project is to describe the effect of this simulated immersion on student empathy and attitudes toward diabetes. METHOD: The DPT students (n=59) participated in 12 cine-VR education modules, completing surveys at three time points as part of coursework. The students completed baseline measures of the Diabetes Attitude Scale-Version 3 (DAS-3) and Jefferson Empathy Scale (JES), and then were immersed in 12 cine-VR modules. One week after module completion, students participated in a class discussion about the modules. The students repeated the JES and DAS-3 scales at postclass and six weeks later. Three subscales from the Presence Questionnaire (PQ) were used to measure the virtual experience. RESULTS: Student scores on three DAS-3 subscales significantly improved on posttest: Attitude toward patient autonomy, Mean: 0.75, SD: 0.45; t(58) = 12.742, P < .001; Psychosocial impact of diabetes, Mean: -0.21, SD: 0.41; t(58) = -3.854, P < .001; and Seriousness of type 2 diabetes, Mean: -039, SD: 0.44; t(58) = -6.780, P < .001, with lower scores six weeks later. Student scores increased on the JES and remained high (P < .001). High subscale scores on the PQ demonstrated immersion and involvement in the virtual experience. DISCUSSION: These modules can allow for a shared student experience that improves diabetes attitudes, increases empathy, and fosters meaningful classroom discussion. The cine-VR experience is flexible, and modules allow students to engage in aspects of a patient's life that were not available otherwise.

Going into town or staying home: Rural patient experience and preference with home-based versus clinic-based telehealth.

INTRODUCTION: Telehealth is a model of care with potential to improve access, and in turn outcomes, for people living in rural areas. Since 2013, our endocrine clinic-based telehealth program has provided care at rural community hospitals in Nebraska and Iowa. At the start of the COVID-19 pandemic, when regulations around telehealth were adjusted, patients previously seen via clinic-based telehealth had the option to continue clinic-based visits or have a home-based telehealth visit. There is no literature comparing patient experiences between home-based and clinic-based telehealth. The purpose of this study was to understand rural patient preferences regarding endocrinology home-based versus clinic-based telehealth visits. METHODS: This was a survey study of adult, rural patients who experienced both a clinic-based and home-based telehealth visit with their established endocrinology provider. Respondents were asked about demographics, their reason for visit, preference for home versus clinic-based telehealth, and how they would have received care if telehealth were not an option. RESULTS: Forty-two patients (40.8%) responded to the survey, with 27 patients (64.3%) preferring home-based telehealth. There were no significant differences between the groups. However, 47.5% of patients would not have sought specialty care if telehealth were not an option. DISCUSSION: This survey of endocrine patients experienced in both clinic-based and home-based telehealth indicates that, while most respondents preferred home-based telehealth, there are distinct advantages to each model and patients appreciate having options. We believe it is important to maintain both lines of service to provide patient-centered care and improve access to specialty care.

Physician Assistant Student Attitudes and Empathy Following Virtual Immersion.

BACKGROUND: Addressing provider attitudes associated with diabetes and social determinants of health (SDH) can help improve a patient's overall health and wellbeing. Empathy can improve patient care and outcomes. Cinematic virtual reality (Cine-VR) has been shown to positively affect student empathy. The purpose of this study was to measure and compare empathy and diabetes attitudes among physician assistant students following immersion in 12 virtual-reality video modules. METHODS: Students (n=57) completed the Diabetes Attitude Scale-version 3 (DAS-3) and Jefferson Empathy Scale (JES) before and after completion of the modules. Data were analyzed using paired t-tests to determine differences in scales from baseline to post. RESULTS: After viewing the 12 modules, four DAS-3 subscales significantly increased and the JES showed increases from baseline to post, although not significant. DISCUSSION: Utilization of a common virtual patient can help engage students in improving attitudes toward patients with diabetes experiencing SDH and enhancing empathy.

Are We Missing an Opportunity? Prediabetes in the U.S. Military.

INTRODUCTION: The prevalence of prediabetes is estimated to be one-third of Americans with approximately 80% of these individuals unaware of the diagnosis. In the active duty military population, the prevalence of prediabetes is largely unexplored. The purpose of this study was to investigate the prevalence of prediabetes in military service members by quantifying those meeting prediabetes screening criteria, those actually being screened, and those being appropriately diagnosed. MATERIALS AND METHODS: Data were analyzed from calendar years 2014 to 2018 for active duty service members 18 years of age or older. Vitals records were collected to obtain body mass index values. Composite Health Care System laboratory data were queried for hemoglobin A1c (HbA1c) results as well as fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) results. The percentage of active duty service members meeting criteria for prediabetes screening was determined by totaling members age 45 and older with members age 18- to 44-year old with a body mass index ≥25.0 kg/m2, then dividing by the total number of members for each respective military branch. The percentage of active duty service members actually screened for prediabetes was determined based on members meeting prediabetes screening criteria who in fact had FPG, OGTT, or HbA1c labs. The total number of labs meeting prediabetes criteria was determined based on those aforementioned labs with results in the prediabetes range (FPG between 100 and 125 mg/dL, OGTT between 140 and 199 mg/dL, or HbA1c range of 5.7%-6.4%). The total number of service members with appropriate prediabetes International Classification of Disease (ICD) code was determined by identifying members with ICD-9 and ICD-10 codes 790.21, 790.22, and R73.01-R73.03 in their medical record. RESULTS: From 2014 to 2018, 53.9% of 332,502, 56% of 543,081, and 47.3% of 531,313 active duty service members in the Air Force, Army and Navy, respectively, met criteria for prediabetes screening. The rates of actually screening for prediabetes were similar across the Air Force (4.8%), Army (6.7%), and Navy (5.5%). The percentage with labs meeting prediabetes criteria ranged from 17.9% to 28.4% in the Air Force, 24.2% to 30.3% in the Army, and 24.2% to 30.9% in the Navy. The rate of ICD coding for prediabetes increased from 2014 to 2018 across all branches (29.8%-65.3% for the Air Force, 24.6%-46.8% for the Army, and 40.0%-45.5% for the Navy). CONCLUSION: Screening for prediabetes in the active duty military population is grossly inadequate, and even of those screened, diagnosing those meeting prediabetes criteria is similarly inadequate. Although this scenario is not unique to the Military Health System, but reflective of a larger national problem, efforts should be made within the Military Health System to increase the screening for this common disorder. Identifying service members with prediabetes enables opportunities for targeted interventions to delay or prevent the progression to diabetes mellitus.