- Email: [email protected]
Glucose Targets in Older Adults With Diabetes: An Evolving Landscape
Letters to the Editor / JAMDA 14 (2013) 132e145
INRA, UMR 1019, UNH, CRNH Auvergne, Clermont-Ferrand, France CHU Clermont-Ferrand, Service de Nutrition Clinique Clermont-Ferrand, France
143
Discharge transc. #: ______________ Date: __________ Time: ___________ Dr. _________________________ was
http://dx.doi.org/10.1016/j.jamda.2012.10.017
called/voice mailed/e-mailed/texted Pt sent: home/hosp/NH/asst living Fig. 1. Chart Notation Example
Carrot or Stick? Improving the Discharge Process To the Editor: Readmission rates have become a major concern to the Medicare program, which views them as potentially avoidable and largely the result of poor discharge planning. An important part of any effort to improve the discharge process and reduce readmissions is better communication between the discharging hospitalist and the patient’s primary care physician. Medicare is planning to use a “stick,” denial of payment for any readmission within 30 days of discharge, hoping thereby to force improvement in the discharge process. Any changes in how transition of care is improved to meet this challenge would certainly include a mandate for the hospitalist to call the downstream physician. I believe that poor communication between physicians is a real problem, but that clinicians can come up with solutions and that using a “carrot,” a reward, is more likely to change behavior than using a “stick,” or denial of payment. Why have readmission rates drawn so much attention? Is this a new problem, and is it possible that changes to the discharge process can improve these rates? Before the advent of hospitalists, the patient’s primary physician saw them in the hospital and knew what the plan of care was to be after discharge. Now, without a phone call or early access to a written plan or discharge summary, the physician may be totally in the dark. They may not even have known that their patient was in the hospital. Because most hospitalists have not been in an outpatient practice, they do not know that the most embarrassing situation for any outpatient physician, and one that leads to wasted time and disjointed care, is to have a patient come into the office and state: “I was hospitalized last week. What do I do now?” Several hospitalists have told me that communicating the discharge plan was “up to the discharge coordinator.” Many hospitalists say that calling the receiving physician takes too much time, they can never get through, or that their calls are not returned. Some hospitals have set up hospitalist staffed discharge clinics, make phone contact after discharge, or make early home visits by specialized nurses rather than taking the obvious step of contacting the patient’s regular physician and discussing the discharge plan. Medicare is so convinced that the receiving physician needs to be “in the loop” that it is proposing a new payment category for discharge care coordination by the primary physician. As a quality improvement project, linked to an opportunity for a cash bonus, a carrot, I challenged my team of SNFists (three physicians and a nurse practitioner) to contact at least 85% of the physicians receiving our discharged patients with information about the discharge plan. To score this effort, I placed a designated site in the chart where the discharge transcription number, the date and time, the contacted physician’s name, how they were contacted, and the patient’s destination on discharge were recorded or indicated by circling the appropriate category (Figure 1).
After 6 months, a survey of the charts of 340 discharged patients, randomly chosen, revealed that we called, left voice mails, e-mailed, or texted 94% of the receiving physicians. Although I prefer phone calls, most younger physicians prefer e-mailing and texting. Presumably, most office-based physicians are also comfortable with those methods of communication, although Health Insurance Portability and Accountability Act of 1996e protected patient information must never be sent this way unless it is encrypted. Every downstream physician appreciated the calls, and almost every physician who was unavailable to talk when we first called returned our calls promptly, without necessitating a second attempt on our part. Many physicians had not known their patient was hospitalized. A side benefit of these calls was the opportunity to arrange an early follow-up appointment. When the patient or the hospital’s discharge personnel call for an appointment at the time of discharge, the office may not schedule it for weeks, or even months later, an obvious recipe for an early readmission! The next obvious step will be to compare the readmission rates of our patients with readmission rates in general, but the relatively small effort and time commitment required to achieve this goal suggest that, even if these calls result in only a modest decline in readmission rates, the effort is well worthwhile. Arthur Vall-Spinosa, MD Medical Director, Kaseman Rehabilitation Albuquerque, NM
http://dx.doi.org/10.1016/j.jamda.2012.09.018
Glucose Targets in Older Adults With Diabetes: An Evolving Landscape To the Editor: The position statement on diabetes mellitus in older people on behalf of the International Association of Gerontology and Geriatrics and the European Diabetes Working Party for Older People in the July issue of this journal is an important addition to clinical guidelines addressing this issue.1 It is succinct and provides consensus statements on several aspects of diabetes care that continue to cause concern to clinicians managing older adults with diabetes and other comorbidities across the care continuum. These are appropriate glucose targets, the influence of comorbidities, patient safety, therapy, and management of diabetes in long-term facilities, to name a few.
144
Letters to the Editor / JAMDA 14 (2013) 132e145
The authors make clear recommendations whenever possible, but do not make these rigid or prescriptive, thus allowing practitioners to make individualized decisions for patients with varying disease duration, severity of complications, and presence of other geriatric syndromes or the overall “diabetes burden.” The glucose targets recommending avoidance of fasting glucose less than 6.0 mmol/L on treatment, only commencing therapy if fasting glucose is consistently greater than 7.0 mmol/L, and avoiding glucose levels less than 5.0 mmol/L or more than 11.0 mmol/L provide a useful operating framework and could be applied to most care settings, other than in hospice. However, the suggested HbA1c target of 7.0% to 7.5% may be too “tight” for many patients. Older adults may have unrecognized episodes of hypoglycemia even when they have poor glycemic control. Munshi and colleagues’2 study of 3-day glucose profiles in community-dwelling older adults undergoing continuous glucose monitoring showed that 26 of 40 patients (65%) older than 69 years with HbA1c greater than 8% had at least 1 episode of hypoglycemia with a median glucose level of 3.5 mmol/L. Of the patients with hypoglycemia, 46% had glucose levels less than 2.8 mmol/L, and of the 102 episodes of hypoglycemia, 95% were unrecognized by symptoms or glucose monitoring. Older adults with diabetes have greater functional decline,3 and a recent study of 376 clients of the On Lok Lifeways PACE program (mean age 80 years and 50% were taking insulin) showed that at 2 years, higher HbA1c was associated with less functional decline or death.4 After accounting for confounding factors, HbA1c of 8.0% to 8.9% was associated with a lower likelihood of functional decline or death than HbA1c of 7.0% to 7.9%. Another argument for considering higher HbA1c targets may be the increased incidence of hip fractures in older adults with diabetes. Puar and colleagues5 found a three-fold increase in the odds of hip fracture for HbA1c levels less than 6% compared with levels greater than 8%, and 2-fold odds of fracture for HbA1c between 6% and 7% in a caseecontrol study of 558 older adults (mean age 77 years) hospitalized for hip fracture. Although I think the position statement1 on diabetes mellitus in older adults makes a significant contribution to clinical decision making for managing patients with diabetes and multimorbidity, the general recommendation of HbA1c target between 7% and 7.5% may be worth reexamining in the future. References 1. Sinclair A, Morley JE, Rodriguez-Manas L, et al. Diabetes mellitus in older people: Position Statement on people on behalf of the International Association of Gerontology and Geriatrics (IAGG) and the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497e502. 2. Munshi MN, Segal AR, Suhl E, et al. Frequent hypoglycemia among elderly patients with poor glycemic control. Arch Intern Med 2011;171: 362e364. 3. Gregg EW, Beckles GL, Williamson DF, et al. Diabetes and physical disability among older U.S. adults. Diabetes Care 2000;23:1272e1277. 4. Yau CK, Eng C, Cenzer IS, et al. Glycosylated hemoglobin and functional decline in community-dwelling nursing home-eligible elderly adults with diabetes mellitus. J Am Geriatr Soc 2012;60:1215e1221. 5. Puar et al. Tight glycemic control linked to hip fractures in older diabetic patients. Am Geriatri Soc. Published online August 2, 2012.
Naushira Pandya, MD, CMD Department of Geriatrics The Geriatrics Education Center Nova Southeastern University College of Osteopathic Medicine Ft. Lauderdale, FL
http://dx.doi.org/10.1016/j.jamda.2012.10.005
Protein Supplementation and Physical Function: Muscular and Cognitive Perspectives
To the Editor: I read with much interest 2 recent randomized placebocontrolled trials reported by Tieland and colleagues in the October 2012 issue of the Journal of American Medical Directors Association.1,2 The authors reported that an additional protein intake (30 g/d) in the form of protein supplementation (15 g protein twice daily) for 24 weeks led to improved physical function in the protein-alone trial,1 and an increased muscle mass in the protein plus resistance exercise trial.2 In the proteinsupplementation groups of the 2 trials, the protein intake was increased from 1.0 g/kg/d to 1.3 to 1.4 g/kg/d. Compared with placebo, protein supplement alone led to better physical function (as measured by the Short Physical Performance Battery [SPPB]).3 In our previous study on malnourished older adults, protein supplementation alone improved physical function after 4 weeks.4 The SPPB score increased from 8.9 to 10.0. A 1-point increase in the SPPB score is clinically relevant, and translates to less disability, institutionalization, and mortality.3,5 However, there were no improvements in the gait speed, muscle mass (measured by dual-energy x-ray absorptiometry and muscle biopsy), and muscle strength (measured by 1 repetition maximum) in the protein-supplemented group. It seems puzzling to have this degree of improvement in physical function, but without an improvement in the muscle mass or strength after protein supplementation. One possibility is the cognitive benefit of enhancing protein intake in older adults. Jakobsen and colleagues6 demonstrated that a high-protein diet improved both muscular and cognitive functions. The cognitive benefit was confined to a decrease in reaction time for demanding tasks (eg, “Go/No go” task), but not for less demanding tasks. The SPPB score is a summary score and derived from 3 components of physical performance: balance, gait speed, and chair-rise ability. In Tieland et al’s first study,1 the observed improvement in the SPPB score was mainly attributable to a better performance in the chair-rise time (for 5 consecutive chair stands) after the protein supplementation. Apart from having good muscle strength of the lower limb, the chair-rise task also depends on the person’s cognitive ability to change quickly from “stand-up” to “sit-down” actions. This alternation or switching of movement requires the cognitive ability to switch and is conceptually similar to the “Go/No go” tasks described in Jakobsen et al’s study.6 Compared with protein supplementation, resistance exercise was much more powerful. In the second companion clinical trial reported by Tieland and colleagues,2 participants of both groups received resistance exercise training for 24 weeks. Only the intervention group was given the protein supplementation (15 g protein twice daily). The authors reported significant improvements in lower limb muscle strength; in the lower limb leg press and extension, muscle strength increased by approximately 40% in both groups. Regarding physical function, both groups experienced similar degrees of improvements in the SPPB score and chair-rise time. Unlike the first trial,1 there was no further benefit on physical function in the protein-supplemented versus the placebo groups.2 The only additional benefit of protein supplementation was an increase in the muscle mass (mainly the appendicular muscle mass).2 It was still unexplained how this degree of increased muscle mass, which was not
INRA, UMR 1019, UNH, CRNH Auvergne, Clermont-Ferrand, France CHU Clermont-Ferrand, Service de Nutrition Clinique Clermont-Ferrand, France
143
Discharge transc. #: ______________ Date: __________ Time: ___________ Dr. _________________________ was
http://dx.doi.org/10.1016/j.jamda.2012.10.017
called/voice mailed/e-mailed/texted Pt sent: home/hosp/NH/asst living Fig. 1. Chart Notation Example
Carrot or Stick? Improving the Discharge Process To the Editor: Readmission rates have become a major concern to the Medicare program, which views them as potentially avoidable and largely the result of poor discharge planning. An important part of any effort to improve the discharge process and reduce readmissions is better communication between the discharging hospitalist and the patient’s primary care physician. Medicare is planning to use a “stick,” denial of payment for any readmission within 30 days of discharge, hoping thereby to force improvement in the discharge process. Any changes in how transition of care is improved to meet this challenge would certainly include a mandate for the hospitalist to call the downstream physician. I believe that poor communication between physicians is a real problem, but that clinicians can come up with solutions and that using a “carrot,” a reward, is more likely to change behavior than using a “stick,” or denial of payment. Why have readmission rates drawn so much attention? Is this a new problem, and is it possible that changes to the discharge process can improve these rates? Before the advent of hospitalists, the patient’s primary physician saw them in the hospital and knew what the plan of care was to be after discharge. Now, without a phone call or early access to a written plan or discharge summary, the physician may be totally in the dark. They may not even have known that their patient was in the hospital. Because most hospitalists have not been in an outpatient practice, they do not know that the most embarrassing situation for any outpatient physician, and one that leads to wasted time and disjointed care, is to have a patient come into the office and state: “I was hospitalized last week. What do I do now?” Several hospitalists have told me that communicating the discharge plan was “up to the discharge coordinator.” Many hospitalists say that calling the receiving physician takes too much time, they can never get through, or that their calls are not returned. Some hospitals have set up hospitalist staffed discharge clinics, make phone contact after discharge, or make early home visits by specialized nurses rather than taking the obvious step of contacting the patient’s regular physician and discussing the discharge plan. Medicare is so convinced that the receiving physician needs to be “in the loop” that it is proposing a new payment category for discharge care coordination by the primary physician. As a quality improvement project, linked to an opportunity for a cash bonus, a carrot, I challenged my team of SNFists (three physicians and a nurse practitioner) to contact at least 85% of the physicians receiving our discharged patients with information about the discharge plan. To score this effort, I placed a designated site in the chart where the discharge transcription number, the date and time, the contacted physician’s name, how they were contacted, and the patient’s destination on discharge were recorded or indicated by circling the appropriate category (Figure 1).
After 6 months, a survey of the charts of 340 discharged patients, randomly chosen, revealed that we called, left voice mails, e-mailed, or texted 94% of the receiving physicians. Although I prefer phone calls, most younger physicians prefer e-mailing and texting. Presumably, most office-based physicians are also comfortable with those methods of communication, although Health Insurance Portability and Accountability Act of 1996e protected patient information must never be sent this way unless it is encrypted. Every downstream physician appreciated the calls, and almost every physician who was unavailable to talk when we first called returned our calls promptly, without necessitating a second attempt on our part. Many physicians had not known their patient was hospitalized. A side benefit of these calls was the opportunity to arrange an early follow-up appointment. When the patient or the hospital’s discharge personnel call for an appointment at the time of discharge, the office may not schedule it for weeks, or even months later, an obvious recipe for an early readmission! The next obvious step will be to compare the readmission rates of our patients with readmission rates in general, but the relatively small effort and time commitment required to achieve this goal suggest that, even if these calls result in only a modest decline in readmission rates, the effort is well worthwhile. Arthur Vall-Spinosa, MD Medical Director, Kaseman Rehabilitation Albuquerque, NM
http://dx.doi.org/10.1016/j.jamda.2012.09.018
Glucose Targets in Older Adults With Diabetes: An Evolving Landscape To the Editor: The position statement on diabetes mellitus in older people on behalf of the International Association of Gerontology and Geriatrics and the European Diabetes Working Party for Older People in the July issue of this journal is an important addition to clinical guidelines addressing this issue.1 It is succinct and provides consensus statements on several aspects of diabetes care that continue to cause concern to clinicians managing older adults with diabetes and other comorbidities across the care continuum. These are appropriate glucose targets, the influence of comorbidities, patient safety, therapy, and management of diabetes in long-term facilities, to name a few.
144
Letters to the Editor / JAMDA 14 (2013) 132e145
The authors make clear recommendations whenever possible, but do not make these rigid or prescriptive, thus allowing practitioners to make individualized decisions for patients with varying disease duration, severity of complications, and presence of other geriatric syndromes or the overall “diabetes burden.” The glucose targets recommending avoidance of fasting glucose less than 6.0 mmol/L on treatment, only commencing therapy if fasting glucose is consistently greater than 7.0 mmol/L, and avoiding glucose levels less than 5.0 mmol/L or more than 11.0 mmol/L provide a useful operating framework and could be applied to most care settings, other than in hospice. However, the suggested HbA1c target of 7.0% to 7.5% may be too “tight” for many patients. Older adults may have unrecognized episodes of hypoglycemia even when they have poor glycemic control. Munshi and colleagues’2 study of 3-day glucose profiles in community-dwelling older adults undergoing continuous glucose monitoring showed that 26 of 40 patients (65%) older than 69 years with HbA1c greater than 8% had at least 1 episode of hypoglycemia with a median glucose level of 3.5 mmol/L. Of the patients with hypoglycemia, 46% had glucose levels less than 2.8 mmol/L, and of the 102 episodes of hypoglycemia, 95% were unrecognized by symptoms or glucose monitoring. Older adults with diabetes have greater functional decline,3 and a recent study of 376 clients of the On Lok Lifeways PACE program (mean age 80 years and 50% were taking insulin) showed that at 2 years, higher HbA1c was associated with less functional decline or death.4 After accounting for confounding factors, HbA1c of 8.0% to 8.9% was associated with a lower likelihood of functional decline or death than HbA1c of 7.0% to 7.9%. Another argument for considering higher HbA1c targets may be the increased incidence of hip fractures in older adults with diabetes. Puar and colleagues5 found a three-fold increase in the odds of hip fracture for HbA1c levels less than 6% compared with levels greater than 8%, and 2-fold odds of fracture for HbA1c between 6% and 7% in a caseecontrol study of 558 older adults (mean age 77 years) hospitalized for hip fracture. Although I think the position statement1 on diabetes mellitus in older adults makes a significant contribution to clinical decision making for managing patients with diabetes and multimorbidity, the general recommendation of HbA1c target between 7% and 7.5% may be worth reexamining in the future. References 1. Sinclair A, Morley JE, Rodriguez-Manas L, et al. Diabetes mellitus in older people: Position Statement on people on behalf of the International Association of Gerontology and Geriatrics (IAGG) and the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497e502. 2. Munshi MN, Segal AR, Suhl E, et al. Frequent hypoglycemia among elderly patients with poor glycemic control. Arch Intern Med 2011;171: 362e364. 3. Gregg EW, Beckles GL, Williamson DF, et al. Diabetes and physical disability among older U.S. adults. Diabetes Care 2000;23:1272e1277. 4. Yau CK, Eng C, Cenzer IS, et al. Glycosylated hemoglobin and functional decline in community-dwelling nursing home-eligible elderly adults with diabetes mellitus. J Am Geriatr Soc 2012;60:1215e1221. 5. Puar et al. Tight glycemic control linked to hip fractures in older diabetic patients. Am Geriatri Soc. Published online August 2, 2012.
Naushira Pandya, MD, CMD Department of Geriatrics The Geriatrics Education Center Nova Southeastern University College of Osteopathic Medicine Ft. Lauderdale, FL
http://dx.doi.org/10.1016/j.jamda.2012.10.005
Protein Supplementation and Physical Function: Muscular and Cognitive Perspectives
To the Editor: I read with much interest 2 recent randomized placebocontrolled trials reported by Tieland and colleagues in the October 2012 issue of the Journal of American Medical Directors Association.1,2 The authors reported that an additional protein intake (30 g/d) in the form of protein supplementation (15 g protein twice daily) for 24 weeks led to improved physical function in the protein-alone trial,1 and an increased muscle mass in the protein plus resistance exercise trial.2 In the proteinsupplementation groups of the 2 trials, the protein intake was increased from 1.0 g/kg/d to 1.3 to 1.4 g/kg/d. Compared with placebo, protein supplement alone led to better physical function (as measured by the Short Physical Performance Battery [SPPB]).3 In our previous study on malnourished older adults, protein supplementation alone improved physical function after 4 weeks.4 The SPPB score increased from 8.9 to 10.0. A 1-point increase in the SPPB score is clinically relevant, and translates to less disability, institutionalization, and mortality.3,5 However, there were no improvements in the gait speed, muscle mass (measured by dual-energy x-ray absorptiometry and muscle biopsy), and muscle strength (measured by 1 repetition maximum) in the protein-supplemented group. It seems puzzling to have this degree of improvement in physical function, but without an improvement in the muscle mass or strength after protein supplementation. One possibility is the cognitive benefit of enhancing protein intake in older adults. Jakobsen and colleagues6 demonstrated that a high-protein diet improved both muscular and cognitive functions. The cognitive benefit was confined to a decrease in reaction time for demanding tasks (eg, “Go/No go” task), but not for less demanding tasks. The SPPB score is a summary score and derived from 3 components of physical performance: balance, gait speed, and chair-rise ability. In Tieland et al’s first study,1 the observed improvement in the SPPB score was mainly attributable to a better performance in the chair-rise time (for 5 consecutive chair stands) after the protein supplementation. Apart from having good muscle strength of the lower limb, the chair-rise task also depends on the person’s cognitive ability to change quickly from “stand-up” to “sit-down” actions. This alternation or switching of movement requires the cognitive ability to switch and is conceptually similar to the “Go/No go” tasks described in Jakobsen et al’s study.6 Compared with protein supplementation, resistance exercise was much more powerful. In the second companion clinical trial reported by Tieland and colleagues,2 participants of both groups received resistance exercise training for 24 weeks. Only the intervention group was given the protein supplementation (15 g protein twice daily). The authors reported significant improvements in lower limb muscle strength; in the lower limb leg press and extension, muscle strength increased by approximately 40% in both groups. Regarding physical function, both groups experienced similar degrees of improvements in the SPPB score and chair-rise time. Unlike the first trial,1 there was no further benefit on physical function in the protein-supplemented versus the placebo groups.2 The only additional benefit of protein supplementation was an increase in the muscle mass (mainly the appendicular muscle mass).2 It was still unexplained how this degree of increased muscle mass, which was not