Postoperative Glucose Control and SCIP Measures. Gorav Ailawadi, MD Chief, Adult Cardiac Surgery University of Virginia April 25, 2015

Similar documents
Preoperative Anemia versus Blood Transfusion: Which is the Culprit for Worse Outcomes in Cardiac Surgery?

Disclosures. Glycemic Control in the Intensive Care Unit. Objectives. Hyperglycemia. Hyperglycemia. History. No disclosures

Deepika Reddy MD Department of Endocrinology

VANDERBILT UNIVERSITY MEDICAL CENTER MULTIDISCIPLINARY SURGICAL CRITICAL CARE TRAUMA INTENSIVE CARE UNIT GLYCEMIC CONTROL PROTOCOL

Contemporary outcomes for surgical mitral valve repair: A benchmark for evaluating emerging mitral valve technology

In - Hospital Diabetes Care. A review and personal experience

Control of Blood Glucose in the ICU: Reconciling the Conflicting Data

Journal Club ICU

Measure Information Form


INTENSIVE INSULIN THERAPY: A Long History of Conflicting Data.

123 Are You Providing Evidence-Based Diabetes Care? - Martin

Transition of Care in Hospitalized Patients with Hyperglycemia and Diabetes

Received: 23 September Accepted: 17 October 2009

GLYCEMIC CONTROL SURVEY

The Portland Diabetic Project: Hyperglycemia/Mortality Hypothesis

What Should Be the Therapeutic Glycemic Target in Intensive Care Units?

THE NATIONAL QUALITY FORUM

Inpatient Glycemic Management 2016

Glycemic Control Insulin In The Hospital Setting

Marc Albert, Adrian Ursulescu, Ulrich FW Franke Department of Cardiovascular Surgery Robert-Bosch-Hospital, Stuttgart, Germany

GRADE for reducing adversegrade for reducing adverse outcomes. outcomes

Management of Inpatient Hyperglycemia: 2011 Endocrine Society Meeting Hyperglycemia in Critically ill patients in ICU Settings.

A Children s Bedtime Story

MANAGEMENT OF HYPERGLYCEMIA IN CRITICALLY ILL SURGICAL (NON-CARDIAC) PATIENTS

CORONARY ARTERY BYPASS GRAFT (CABG) MEASURES GROUP OVERVIEW

Vijayaprasad Gopichandran, Shriraam Mahadevan, Latha Ravikumar, Gomathy Parasuraman, Anjali Sathya, Bhuma Srinivasan, Usha Sriram

GLYCEMIC CONTROL IN CARDIAC SURGERY: IMPLEMENTING AN EVIDENCE-BASED INSULIN INFUSION PROTOCOL. Critical Care Evaluation

GLYCEMIC CONTROL SURVEY

Hyperglycemia is common among medical and surgical. Clinical Guideline

A Novel Score to Estimate the Risk of Pneumonia After Cardiac Surgery

Transfusion & Mortality. Philippe Van der Linden MD, PhD

Initial Management of Septic Patients with Hyperglycemia in the Noncritical Care Inpatient Setting

Controversies in Hospital Medicine: Critical Care. Vasopressors, Steroids, and Insulin Therapy

QI Successes & Failures Learning from Both

10.4.a. Optimal glucose control: Insulin therapy March 2013

Inpatient Management of Diabetes Mellitus. Jessica Garza, Pharm.D. PGY-1 Pharmacotherapy Resident TTUHSC School of Pharmacy

The Diabetes Link to Heart Disease

The New Priority: Decreasing Readmissions after Cardiothoracic Surgery: How Do We Get There?

GLYCEMIC CONTROL IN NEUROCRITICAL CARE PATIENTS

April Dear (Editor):

JAMA. 2011;305(24): Nora A. Kalagi, MSc

Ischemic Heart Disease Interventional Treatment

2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Outcome

2016 Physician Quality Reporting System Data Collection Form: Coronary Artery Bypass Graft (CABG) (for patients aged 18 years and older)

PAPER. Glycemic Control and Reduction of Deep Sternal Wound Infection Rates

Ischemic Heart Disease Interventional Treatment

Update in Critical Care Medicine

AATS Annual Meeting Seattle, WA Irving Kron, M.D. Professor and Chairman Department of Surgery University of Virginia Hospital Charlottesville,

Intraoperative application of Cytosorb in cardiac surgery

FINANCIAL IMPLICATIONS OF GLYCEMIC CONTROL: RESULTS OF AN INPATIENT DIABETES MANAGEMENT PROGRAM

ACUTE ABDOMEN IN DIABETIC PATIENTS ANALYSIS OF COMPLICATIONS AND MORTALITY

The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: A systematic review protocol

Outcomes and Perioperative Hyperglycemia in Patients With or Without Diabetes Mellitus Undergoing Coronary Artery Bypass Grafting

Insulin sensitivity, its variability and glycaemic outcome:

Martin J Stevens MD, FRCP, Endocrinologist and Professor of Medicine

including prevention, healthy lifestyle behaviors, populations at risk & disparities (age, race/ ethnicity, gender, geographic & socioeconomic)

NEW JERSEY 2012 HOSPITAL PERFORMANCE REPORT TECHNICAL REPORT: METHODOLOGY RECOMMENDED CARE (PROCESS OF CARE) MEASURES

Surgical Care, Pneumonia, Immunizations and Emergency Department Core Measures

NEW JERSEY 2011 HOSPITAL PERFORMANCE REPORT TECHNICAL REPORT: METHODOLOGY RECOMMENDED CARE (PROCESS OF CARE) MEASURES

Effect of SGLT-2 Inhibitors on the Heart. Robert Zimmerman MD Vice Chairman Endocrinology Director Diabetes Center Cleveland Clinic

Disclosures The PREVENT IV Trial was supported by Corgentech and Bristol-Myers Squibb

Glucose Management in the ICU: The Role of the Pharmacist

Intensive Insulin Therapy for Tight Glycemic Control

FEV1 predicts length of stay and in-hospital mortality in patients undergoing cardiac surgery

Inpatient Diabetes Management: The Slippery Slope of Sliding Scale Insulin

Hyperglycemia occurs frequently in critically ill patients.

On-Pump vs. Off-Pump CABG: The Controversy Continues. Miguel Sousa Uva Immediate Past President European Association for Cardiothoracic Surgery

Welcome Everyone. Monitoring, Sick Days, Inpatient Management - Objectives. Mrs. Jones has new diabetes. She asks you: Page 1

The Cardiac Surgeon of the Future

Parenteral Nutrition The Sweet and Sour Truth. From: Division of Endocrinology, Diabetes and Bone Disease Icahn School of Medicine at Mount Sinai

2012 Core Measures. Acute Myocardial Infarction (AMI)

Toledo Hospital Clinical Quality Indicators. Effective - Heart Attack

EVALUATION OF NOSOCOMIAL INFECTION RATES IN DIABETIC PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING (CABG) SURGERY. By Ali A.

Perioperative Glycemic Control

The effect of preoperative liver dysfunction on cardiac surgery outcomes

Cleveland Clinic Cardiovascular Intensive Care Unit Insulin Conversion Protocol

9 Diabetes care. Back to contents

Nova Scotia Guidelines for Acute Coronary Syndromes (Updating the 2008 Diabetes sections of the Guidelines)

Endocrine and Metabolic Complications in the ICU

Outcomes of Surgical Aortic Valve Replacement in Moderate Risk Patients: Implications for Determination of Equipoise in the Transcatheter Era

Diabetes Guidelines in View of Recent Clinical Trials Are They Still Applicable?

ESPEN Congress Madrid 2018

Measure #167 (NQF 0114): Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure National Quality Strategy Domain: Effective Clinical Care

What s so sweet about glycemic control? June 3, 2016

SCORES FOR 4 TH QUARTER, RD QUARTER, 2014

GLUCOSE CONTROL IN THE SURGICAL SETTING

OPCAB IS NOT BETTER THAN CONVENTIONAL CABG

2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Process

Surgical Consensus Standards Endorsement Maintenance NQF-Endorsed Surgical Maintenance Standards (Phase I) Table of Contents

In the United States, 97 million overweight or obese

Hypoglycemia Task Force: A Quality Improvement Initiative to Reduce Inpatient Hypoglycemia

9/23/09. What are the key components of preoperative, intraoperative, & postoperative care of diabetes management? Rebecca L. Sturges, M.D.

Physical Activity/Exercise Prescription with Diabetes

A nationwide population-based study. Pai-Feng Hsu M.D. Shao-Yuan Chuang PhD

Intensive Insulin in the Intensive Care Unit

ESPEN Congress Lisbon Water and electrolytes. Hyperglycemia management. G Van Den Berghe

Proprietary Acute Care Indicators

Accurate Timing of Insulin Administration.

Transcription:

Postoperative Glucose Control and SCIP Measures Gorav Ailawadi, MD Chief, Adult Cardiac Surgery University of Virginia April 25, 2015

Diabetes in CABG Incidence of Diabetes in cardiac surgery increased 85% over last 25 years 37% of Isolated CABG have Diabetes 50% of patients develop perioperative hyperglycemia

Hyperglycemia and Mortality Non-diabetics with hyperglycemia have higher mortality than those with controlled Diabetes Well known perioperative hyperglycemia increases mortality Perioperative glycemic control improves mortality and morbidity

Outline 1. History of SCIP measures 2. Studies from our Center 3. Current Practice

SCIP Measures History Designed to decrease Infection/ Improve outcomes Developed metrics that hospitals must achieve 1. 2006: Post Cardiac Surgery POD 1 or 2 (0600) glucose < 180 2. 2013: Maintain glucose <180 in first day following surgery including 0600 3. 2014: SCIP measures for glucose suspended

What is optimal glucose control?

Landmark Hyperglycemia Trial Intensive insulin therapy (Glucose 110 mg/dl) reduced mortality compared to Conventional (Glucose <215) in SICU Van den Berghe et al. N Engl J Med 2001

NICE SUGAR Trial Intensive glucose control (Glucose 81-108 mg/dl) had higher mortality versus Conventional (Glucose 180 mg/dl) Finfer et al. N Engl J Med 2009

Study 1 Is Tight Control Better than Moderate Control in Cardiac Surgery?

University of Virginia Isolated CABG (1995-2008) N=8,662 Known Diabetes Mellitus (Type II) OR Developed perioperative hyperglycemia First postoperative glucose >126 mg/dl Postoperative (3 day mean) glucose >126 mg/dl N=4,658 GROUP I Tight 126mg/dl N=134 GROUP II Moderate 126-179mg/dl N=2,785 GROUP III Liberal 180mg/dl N=1,739

Percentage (%) Mortality 4.0 3.0 *P<0.001 2.9 3.4 2.0 2.0 1.0 0.0 Tight Moderate* Liberal

Percentage (%) Major Complications 25.0 20.0 19.4 *P=0.02 15.0 10.0 11.1 14.2 5.0 0.0 Tight Moderate* Liberal

% Hypoglycemia Events Hypoglycemia (1st Postop Glucose 60 mg/dl) 2.0 * *P=0.02 1.5 1.5 1.0 0.5 0.0 0.4 0.1 Tight Moderate Liberal

Summary Moderate glucose control: Less hypoglycemia Less prolonged ventilation 2 day shorter length of stay 30% lower major complication rate 40% lower odds of death

Study 2 Are SCIP measures really useful measure of outcomes?

Study 2 Surgical Care Improvement Project (SCIP) Measure for Postoperative Glucose Control Should Not Be Used as a Measure of Quality Following Cardiac Surgery Damien J. LaPar MD, MSc, James M. Isbell MD, MSCI, John A. Kern MD, Gorav Ailawadi MD, Irving L. Kron MD Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center 39 th Annual Meeting Western Thoracic Surgical Association Coeur d Alene, ID

UVA: 2010-2012 (n=1,703) SCIP (BG 200) (n=1,527) Non-SCIP (BG>200) (n=176) 1:1 Propensity Matching (Nearest Neighbor Methodology) SCIP (BG 200) (n=176) Non-SCIP (BG>200) (n=176)

Median Glucose Level POD 1 POD 2 223 [207, 243] 224 [210, 259] 135 [119, 154] 131 [117, 150]

Propensity Matched Cohort: NO DIFFERENCES Variable SCIP (n=176) Non-SCIP (n=176) Perioperative Myocardial Infarction 0.0 0.6 >0.99 Stroke 2.3 4.0 0.54 Pneumonia 4.5 5.7 0.81 Prolonged Ventilation 15.9 21.6 0.22 Renal Failure 9.7 11.4 0.73 Deep Sternal Wound Infection/Mediastinitis 0.0 0.6 >0.99 Major Sternal Complication 0.0 0.6 >0.99 Composite Major Morbidity 17.6 21 0.5 Operative Mortality 6.2 9.1 0.42 Median Total ICU Length of Stay (Hours) 52 [21,98] 64 [23,116] 0.61 Median Postoperative Length of Stay (Days) 6[4,9] 6 [5,9] 0.08 P

No Association SCIP Status ~ Adjusted Outcomes (CABG Only Patients) Outcome Odds Ratio or Regression Coefficient 95% C.I. or SE P Mortality 1.79 0.44,7.32 0.42 Major Morbidity 1.08 0.41,2.83 0.88 Major Sternal Complications - - - Total ICU Duration (Hours) -14.8 16.7 0.38 Postoperative Length of Stay (Days) -0.1 0.68 0.99

Summary Achieving the SCIP measure for controlled POD 1 and 2 blood glucose is not associated with improved outcomes.

Compliance with the new Surgical Care Improvement Project (SCIP) measure for glycemic control after cardiac surgery is not associated with improved postoperative outcomes James M. Isbell, MD, MSCI, Damien J. LaPar, MD, MSc, To Be Presented at WTSA 2015!!! Robert H. Thiele, MD, John A. Kern, MD, Gorav Ailawadi, MD, Irving L. Kron, MD, Anthony L. McCall, MD, PhD, Jennifer L. Kirby, MD, PhD Western Thoracic Surgical Association Whistler, British Columbia June 24, 2015

Current Practice 2014: we instituted an inpatient CV diabetes consult service with a dedicated NP, aided by an attending endocrinologist Also initiated Glucommander- FDA approved device to aid in optimal BG control

Multidisciplinary Team Jay Isbell, MD Jennifer Kriby, MD Cherie Chaney, NP ICU Intensivist Endocrinologist CV Diabetes Consult

Cut Hyperglycemia by >50% ICU PRE POST % BG <70 0.69 0.72 % BG >180 16.8 9.3 % BG >299 0.98 0.57 FLOOR PRE POST % BG <70 0.71 0.54 % BG >180 32.9 16.3 % BG >299 4.4 1.3 Privileged and Confidential Quality Assurance Document Privileged Under Virginia Code Section 8.01-581.17

Mean Glucose Level DWMBG PRE POST 164.4 145.4 137.3 141.2 4N 4W % DWMBG >180 PRE POST 29.4 10 10.9 5.8 DWMBG = day-weight mean BG average BG for a patient over a day 4N 4W % BG <70 PRE POST 0.69 0.72 0.71 0.54 4N 4W

Blood glucose (mg/dl) FLOOR Day-weighted mean % Day-weighted mean >180 185 175 165 FY2013 CY2014 45 40 35 30 FY2013 CY2014 155 145 25 20 15 135 125 1 2 3 4 5 6 7 8 9 10 11 12 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 % BG <70 3 2.5 2 FY2013 CY2014 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12

Conclusion SCIP measures currently suspended but likely to come back once validated Multidisciplinary approach yields optimal outcomes Midlevel provider on endocrinology/ diabetes service essential for education and excellent outcomes

Questions? Gorav Ailawadi gorav@virginia.edu