Implementing simple algorithms to improve glucose and lipid management in people with diabetes and acute coronary syndrome

Abstract

Aim Diabetes mellitus is associated with increased risk of adverse outcomes following acute coronary syndrome. Translating evidence‐based recommendations into practice is necessary to improve outcomes. We evaluated whether implementing algorithms to guide inpatient care improved glycaemic control, and increased use of sodium–glucose co‐transporter 2 (SGLT2) inhibitors and lipid‐lowering medication in a tertiary cardiac unit. Method A 3‐month audit (phase 1) was conducted to evaluate hyperglycaemia and dyslipidaemia management, and medication prescriptions. Consecutive people with diabetes admitted for acute coronary syndrome were prospectively identified. Target blood glucose level was defined as 5–10 mmol/l. A multidisciplinary committee designed and implemented decision‐support algorithms plus education. A 3‐month post‐implementation audit (phase 2) was conducted. Results There were 104 people in phase 1 and 101 in phase 2, with similar characteristics [HbA1c 64 ± 20 mmol/mol vs. 61 ± 21 mmol/mol (8.0 ± 1.8% vs. 7.8 ± 1.9%]. Post implementation, the incidence of blood glucose levels > 10 mmol/l was lower [phase 1: 46.4% vs. phase 2: 31.8%, rate ratio (RR) = 0.77, 95% confidence intervals (CI) 0.60–0.98; P = 0.031], without a difference in blood glucose levels < 5mmol/l (phase 1: 4.9% vs. phase 2: 4.5%, RR = 1.20, 95% CI 0.70–2.08; P = 0.506). SGLT2 inhibitor prescriptions increased significantly (baseline to discharge: 12.5% to 15.4% vs. 7.9% to 24.8%; P = 0.007) but high‐intensity statin prescriptions did not (baseline to discharge: 35.6% to 72.1% vs. 40.6% to 85.1%; P = 0.074). Prescription rates of non‐statin lipid‐lowering medications were not significantly increased. Conclusions Implementing decision‐support algorithms was associated with improved inpatient glycaemic control and increased use of cardioprotective therapies at discharge in people with diabetes and acute coronary syndrome.

A Translational In Vivo and In Vitro Metabolomic Study Reveals Altered Metabolic Pathways in Red Blood Cells of Type 2 Diabetes

“…HbA1c is used by physicians to obtain an overall picture of average blood glucose levels over a long time period (around 2 months) [ 8 , 9 , 10 , 11 ]. Patients with higher HbA1c values are associated with a greater risk of developing diabetes-related complications.…”

Managing inpatient hyperglycaemia and initiating sodium‐glucose cotransporter 2 inhibitor therapy in the setting of diabetes and acute coronary syndrome

“…Multifactorial interventions to reduce morbidity and mortality have become an important part of diabetes care 3 . Quality improvement interventions applied to the inpatient setting can reduce the rates of hyperglycaemia and increase the prescribing of cardioprotective glucose‐lowering medications following an ACS, thereby improving patient outcomes 4,5 …”

“…We previously implemented education plus decision‐support algorithms to guide doctors, nurses and pharmacists in our Australian tertiary cardiac unit when managing patients with diabetes and ACS (Box 1). 4 This intervention was associated with an improvement in inpatient glycaemic control through the earlier use of basal and bolus subcutaneous insulin at appropriate weight‐based doses, and an increase in the initiation of sodium‐glucose cotransporter 2 (SGLT2) inhibitors at hospital discharge when audited soon after implementation 4 . The further promotion and use of these algorithms occurred at the discretion of the clinicians in the cardiac unit.…”

“…The aim of this repeat audit was to assess whether the improvements in inpatient glycaemic control and the increase in prescription of SGLT2 inhibitors were sustained. The audit was performed in a new cohort of patients in the same cardiac unit and the findings were compared to the pre‐intervention audit that was previously published 4 . This was approved by the hospital research governance office as a quality improvement activity.…”

Priorities and practicalities of prescribing diabetes medicines with cardiovascular and renal protective effects: an Australian perspective

“…general practitioners, cardiologists and nephrologists in diabetes health care. Potential strategies to increase appropriately the use of these medications involve education initiatives and interdisciplinary collaboration 24 . For example, at a local hospital level, decision support algorithms increased the utilisation of cardiovascular and renal protective medications in patients with type 2 diabetes and acute coronary syndrome on discharge from the coronary care unit 24 …”