GLASGOW, SCOTLAND — The overall prevalence of diabetes among inpatients in Liverpool has increased significantly since 1990, according to a follow-up of one of the few studies of inpatient diabetes done during the 1980s and 1990s.
Researchers conducted a point-prevalence study to assess the extent of diabetes among patients admitted to Aintree University Hospital in Liverpool for any reason in 1990. The study was repeated in 2003 to enable comparison of the changes in diabetes prevalence and hospital capacity.
“The strength of the studies is that we went round and examined all the case notes of everyone that was in hospital,” said Dr. Ian McFarlane, a consultant in the department of diabetes and endocrinology at the hospital, who presented the results at the Diabetes U.K. Annual Professional Conference. “But the drawback is that it is just a snapshot view.”
In 1990, the researchers identified 93 diabetes patients in the hospital. Their median age was 74 years and in 26% of cases, the primary admission was related to their diabetes. In 2003, there were more diabetic patients (126 versus 93), but fewer of the admissions—12.6%—were related to diabetes.
Overall, the prevalence of diabetes among inpatients increased significantly from 7% in 1990 to 11.1% in 2003. The proportion of patients referred to the diabetes team also rose: from 10% in 1990 to 27.5% in 2003.
While prevalence of diabetes among inpatients seems to be increasing in line with national trends, the most worrisome figure for Dr. McFarlane was the small proportion of patients who were referred to the specialist team on admission. “Management is suboptimal in patients who are not referred to the diabetes team,” he said. “We considered management inappropriate in 20% of cases in 1990 and 27% in 2003.”
Examples of inappropriate care included high blood sugar being recorded but not followed up on and metformin being given to patients with renal failure. Only 48% of patients had records of diabetes complications present and only 24% had hemoglobin A1c measurements “even though it should be done in everybody,” said Dr. McFarlane.
While the typical length of stay fell from 16 days in 1990 to 12 in 2003, Dr. McFarlane said this was related more to economic pressures than to better treatment. “The total hospital stay has fallen a bit with all the pressure to turn over beds, but people with diabetes still stay twice as long as those without,” he said.
To enable good management of inpatients with diabetes, Dr. McFarlane recommended the hospital use a multidisciplinary inpatient diabetes team that is on call 24 hours a day. He also suggested using a diabetes specialist nurse and ward-based diabetes “link” nurses to communicate with the specialist team, in addition to developing guidelines for diabetic emergencies and for procedures on wards.
One of the beneficial results of having done the 1990 study was to convince hospital managers that there was a substantial problem. “Having demonstrated the size of the problem, we managed to persuade the powers that be to fund an inpatient specialist nurse,” said Dr McFarlane. “But if nurses turn over all the time, the skills that we help teach the staff nurse on the wards are blown around by all the vagaries of the nurses leaving,” he added.
The changes in diabetes demographics among inpatients have occurred against a background of substantial hospital changes in the United Kingdom. There are fewer hospital beds, increasing acute admissions, dramatic alterations to the out-of-hours care provided by general practitioners, and higher bed occupancy, said Dr. McFarlane. But it is the pressure to discharge early that causes inpatient care to fall apart.