NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.
"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.
Dr. Mary T. Korytkowski
Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.
The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).
A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.
Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.
The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).
Dr. Korytkowski said that she has been a consultant to Eli Lilly.