Quality of Inpatient Diabetes Management

Diabetes mellitus is a common comorbidity of hospitalization; in 2003 diabetes was a secondary diagnosis in 17.8% of all adult hospital discharges.1 When undiagnosed diabetes is included, the prevalence of inpatient diabetes or hyperglycemia may be as high as 38%.2 Recent studies show that hyperglycemia in hospitalized patients complicates numerous illnesses and is an independent predictor of adverse outcomes.3 Treatment of inpatient hyperglycemia improves outcomes, including mortality, for patients in surgical intensive care units4 and possibly for those admitted for myocardial infarction.5, 6 For these reasons, the American Diabetes Association and the American College of Endocrinology now recommend that glucose levels of all patients admitted to non‐critical‐care units be maintained below 180 mg/dL.3, 7

Evidence‐based recommendations for achieving these goals include effective protocols for subcutaneous insulin therapy for patients who do not require continuous intravenous insulin infusion. Components of these protocols include use of basal insulin and scheduled nutritional insulin, avoiding use of supplemental (sliding‐scale) insulin alone (which has been shown to be ineffective and possibly deleterious in prior studies),8 and adjustment of insulin orders to reflect nutritional intake, insulin sensitivity, and previous response to therapy.7

We conducted this study to evaluate the current state of glycemic control and adherence to current recommendations on a general medicine service run by hospitalists in a busy teaching hospital. We also sought to correlate insulin‐ordering practices with the quality of glycemic control in these patients.

METHODS

RESULTS

We prospectively identified 123 patients for the study. Subsequently, 16 patients were excluded, 11 who did not have diabetes or inpatient hyperglycemia (most of whom had been placed on insulin prophylactically to avoid steroid‐induced hyperglycemia), 2 who were admitted for diabetic ketoacidosis, 2 who were not on GMS teams 13, and 1 whose data could not be accessed. Characteristics of the remaining 107 study subjects are shown in Table 1. The mean age of the subjects was 65.2 years; 55% were men. Nine patients had no previous diagnosis of diabetes, 43% were taking insulin prior to admission, 14% had severe diabetic complications, and the median HbA_1C was 7.

Regarding insulin‐ordering practices (Table 2), 47 patients (43%) had basal insulin prescribed, while 4% of patients had an order for scheduled mealtime short‐ or rapid‐acting insulin. Of the 89 patients on sliding‐scale insulin, 80 (90%) had orders written for the default sliding scale built into the computerized physician order entry system at BWH. There was no correlation between intensity of the sliding scale and the patient's total daily insulin dose (data not shown). Of the patients on sliding‐scale insulin, 47% were prescribed basal insulin, 39% were prescribed oral agents, and 23% were prescribed neither.

Regarding glucose control, 317 of 1022 glucose meter readings (31%) were greater than 180 mg/dL, and the mean rate of glucose readings greater than 180 mg/dL per patient was also 31%. Approximately three quarters of all patients had at least one routine glucose reading greater than 180 mg/dL, and 35% of patients had at least 40% of their routine glucose readings greater than 180 mg/dL (Table 2). Twelve of 1022 readings (1.2%) were less than 60 mg/dL, and 11% of patients had at least one glucose reading less than 60 mg/dL (Table 2).

Despite a relatively constant percentage of glucose readings greater than 180 mg/dL per patient over the first 5 days of hospitalization (25%36% each day), we found no evidence of change in the percentage of patients prescribed basal insulin or the percentage of insulin given as basal insulin, and there was a small but significant increase in the total amount of insulin prescribed (Table 3). Of the 75 patients with at least one episode of hypo‐ or hyperglycemia, 43 (57%) were ever prescribed basal insulin, 29 (39%) were prescribed oral diabetes agents, and only 26 (35%) had any change to their insulin regimen during the first 5 days of their hospitalization on GMS. Of the 47 patients prescribed basal insulin in the hospital, 41 had been taking insulin prior to admission.

In a multivariable analysis of the mean glucose reading per patient‐day, we found several predictors of lower glucose readings, including diet‐controlled diabetes prior to admission and prescription of oral hypoglycemic medications in the hospital. We also found several predictors of higher glucose readings, including severe diabetic complications and higher glucose level at admission. Finally, we noted variation both by medical team (each composed of 1 medical attending, 1 resident, and 2 interns) and by floor of the hospital (each staffed by a different cadre of nurses). Adjusting for these factors (as well as for the daily use of dextrose‐containing intravenous fluids and steroids, sex, age, Charlson comorbidity score, APACHE 3 score, prior diagnosis of diabetes, HbA_1C level, and length of hospital stay) use of sliding‐scale insulin alone (eg, without scheduled basal or nutritional insulin) was associated with a daily average glucose reading that was 20 mg/dL higher than that for those prescribed scheduled insulin or those not prescribed a sliding scale at all (95% confidence interval, 5.035 mg/dL; Table 4). In a separate analysis, adjusting for the same clinical factors, we could find no relationship between change in daily dose of basal insulin and change in daily average glucose level (data not shown).

DISCUSSION

In this observational study, we found several deficiencies in the management of diabetes and hyperglycemia among hospitalized patients on a hospitalist‐run general medical service. These deficiencies were both in processes of care (eg, limited use of basal and especially nutritional insulin) and in outcomes (ie, glycemic control) compared with national guidelines. We also found evidence of clinical inertia when comparing outpatient to inpatient regimens, when evaluating daily changes in management, and when evaluating responses to previous hyperglycemia. Finally, we demonstrated that use of an insulin sliding scale by itself was associated with worse glycemic control after extensive adjustment for a variety of clinical factors.

Of note, other than the use of sliding‐scale insulin by itself, we could not find a relationship between specific daily adjustments to insulin orders and daily glycemic control in this study. However, we did find differences in glycemic control by medical team and by floor (the latter a proxy for nursing staff). This suggests that glycemic control depends on the exact details of how insulin is managed, rather than on crude measures of insulin adjustment such as change in dose in response to hyperglycemia. These findings also suggest that interventions focused on medical and nursing staff may be able to improve inpatient glycemic control.

The association between the use of oral diabetic agents and improved glucose control was notable and could represent an actual benefit of these agents (especially when added to sliding‐scale insulin by itself) and/or the result of uncontrolled confounding (ie, as a marker of well‐controlled diabetes). Further study is needed to distinguish among these possibilities.

Previous studies have shown evidence of poor inpatient glycemic control as well as the deleterious effects of sliding‐scale insulin by itself.8 This study is perhaps most notable for the suggestion that little, if anything, has changed over the previous decade in this area, despite recent well‐done observational and randomized controlled trials demonstrating the hazards of inpatient hyperglycemia and the publication of expert consensus statements on inpatient glucose management. Strategies to improve glucose control have been investigated to a greater extent in intensive care units12, 13 than on general medical wards,14 perhaps because the strength of evidence is strongest in this setting. Without such strong evidence for general medical patients, factors such as clinician fear of hypoglycemia, clinical inertia, and resistance to institutional change may play predominant roles.

Clinical inertia (ie, recognition of the problem but failure to act)15 has been demonstrated previously in the outpatient management of diabetes16, 17; this study provides evidence of the phenomenon in the inpatient setting. Work by Phillips and colleagues15 has shown that clinical inertia results from at least 3 problems: overestimation of care provided; use of soft reasons to avoid intensification of therapy; and lack of education, training, and practice organization aimed at achieving specific goals. All 3 problems likely contribute to clinical inertia in inpatient diabetes management. Revised educational programs; systems for improving care such as reminders, flow sheets, and order sets; and performance feedback can help address clinical inertia and improve care.15

This study should be viewed in light of its limitations, including relatively small sample size, thus limiting our ability to detect other possible significant predictors of glycemic control, and the use of a single institution, thus limiting generalizability. However, recent data from the University HealthSystem Consortium revealed that our institution was typical of the 37 participating academic medical centers in that study.18 In addition, only 9 patients were identified without a prior diagnosis of diabetes, raising the possibility that some patients with undiagnosed diabetes were missed in our study. However, our search strategy included a daily review of automatically abstracted laboratory values, making this possibility less likely. Strengths of this study include its prospective data collection methods with rigorous inclusion criteria, collection of detailed clinical data, and use of a novel statistical technique to more accurately assess the complex relationship between insulin use and glycemic control, appropriately adjusting for confounding by indication caused by prior glucose measurements.

Future research should focus on patient, clinician, and system barriers to improving inpatient glycemic management, using the clinical inertia framework as a starting point, and on the creation of insulin protocols that can be used and proven effective in the non‐ICU inpatient setting. Also needed are improved measures of the quality of glycemic control, insulin orders, and daily insulin adjustment.

In conclusion, inpatient glycemic management was shown to be in need of improvement. Institutionwide quality improvement efforts should probably target both physician and nursing behavior and should focus on increasing use of basal and nutritional insulin, as proposed in recent guidelines, avoiding use of sliding‐scale insulin by itself, and performing daily insulin adjustment in response to previous hypo‐ or hyperglycemia. Hospitalists can play a major role in these institutionwide quality improvement efforts.

Diabetes mellitus is a common comorbidity of hospitalization; in 2003 diabetes was a secondary diagnosis in 17.8% of all adult hospital discharges.1 When undiagnosed diabetes is included, the prevalence of inpatient diabetes or hyperglycemia may be as high as 38%.2 Recent studies show that hyperglycemia in hospitalized patients complicates numerous illnesses and is an independent predictor of adverse outcomes.3 Treatment of inpatient hyperglycemia improves outcomes, including mortality, for patients in surgical intensive care units4 and possibly for those admitted for myocardial infarction.5, 6 For these reasons, the American Diabetes Association and the American College of Endocrinology now recommend that glucose levels of all patients admitted to non‐critical‐care units be maintained below 180 mg/dL.3, 7

Evidence‐based recommendations for achieving these goals include effective protocols for subcutaneous insulin therapy for patients who do not require continuous intravenous insulin infusion. Components of these protocols include use of basal insulin and scheduled nutritional insulin, avoiding use of supplemental (sliding‐scale) insulin alone (which has been shown to be ineffective and possibly deleterious in prior studies),8 and adjustment of insulin orders to reflect nutritional intake, insulin sensitivity, and previous response to therapy.7

We conducted this study to evaluate the current state of glycemic control and adherence to current recommendations on a general medicine service run by hospitalists in a busy teaching hospital. We also sought to correlate insulin‐ordering practices with the quality of glycemic control in these patients.

METHODS

RESULTS

We prospectively identified 123 patients for the study. Subsequently, 16 patients were excluded, 11 who did not have diabetes or inpatient hyperglycemia (most of whom had been placed on insulin prophylactically to avoid steroid‐induced hyperglycemia), 2 who were admitted for diabetic ketoacidosis, 2 who were not on GMS teams 13, and 1 whose data could not be accessed. Characteristics of the remaining 107 study subjects are shown in Table 1. The mean age of the subjects was 65.2 years; 55% were men. Nine patients had no previous diagnosis of diabetes, 43% were taking insulin prior to admission, 14% had severe diabetic complications, and the median HbA_1C was 7.

Regarding insulin‐ordering practices (Table 2), 47 patients (43%) had basal insulin prescribed, while 4% of patients had an order for scheduled mealtime short‐ or rapid‐acting insulin. Of the 89 patients on sliding‐scale insulin, 80 (90%) had orders written for the default sliding scale built into the computerized physician order entry system at BWH. There was no correlation between intensity of the sliding scale and the patient's total daily insulin dose (data not shown). Of the patients on sliding‐scale insulin, 47% were prescribed basal insulin, 39% were prescribed oral agents, and 23% were prescribed neither.

Regarding glucose control, 317 of 1022 glucose meter readings (31%) were greater than 180 mg/dL, and the mean rate of glucose readings greater than 180 mg/dL per patient was also 31%. Approximately three quarters of all patients had at least one routine glucose reading greater than 180 mg/dL, and 35% of patients had at least 40% of their routine glucose readings greater than 180 mg/dL (Table 2). Twelve of 1022 readings (1.2%) were less than 60 mg/dL, and 11% of patients had at least one glucose reading less than 60 mg/dL (Table 2).

Despite a relatively constant percentage of glucose readings greater than 180 mg/dL per patient over the first 5 days of hospitalization (25%36% each day), we found no evidence of change in the percentage of patients prescribed basal insulin or the percentage of insulin given as basal insulin, and there was a small but significant increase in the total amount of insulin prescribed (Table 3). Of the 75 patients with at least one episode of hypo‐ or hyperglycemia, 43 (57%) were ever prescribed basal insulin, 29 (39%) were prescribed oral diabetes agents, and only 26 (35%) had any change to their insulin regimen during the first 5 days of their hospitalization on GMS. Of the 47 patients prescribed basal insulin in the hospital, 41 had been taking insulin prior to admission.

In a multivariable analysis of the mean glucose reading per patient‐day, we found several predictors of lower glucose readings, including diet‐controlled diabetes prior to admission and prescription of oral hypoglycemic medications in the hospital. We also found several predictors of higher glucose readings, including severe diabetic complications and higher glucose level at admission. Finally, we noted variation both by medical team (each composed of 1 medical attending, 1 resident, and 2 interns) and by floor of the hospital (each staffed by a different cadre of nurses). Adjusting for these factors (as well as for the daily use of dextrose‐containing intravenous fluids and steroids, sex, age, Charlson comorbidity score, APACHE 3 score, prior diagnosis of diabetes, HbA_1C level, and length of hospital stay) use of sliding‐scale insulin alone (eg, without scheduled basal or nutritional insulin) was associated with a daily average glucose reading that was 20 mg/dL higher than that for those prescribed scheduled insulin or those not prescribed a sliding scale at all (95% confidence interval, 5.035 mg/dL; Table 4). In a separate analysis, adjusting for the same clinical factors, we could find no relationship between change in daily dose of basal insulin and change in daily average glucose level (data not shown).

DISCUSSION

In this observational study, we found several deficiencies in the management of diabetes and hyperglycemia among hospitalized patients on a hospitalist‐run general medical service. These deficiencies were both in processes of care (eg, limited use of basal and especially nutritional insulin) and in outcomes (ie, glycemic control) compared with national guidelines. We also found evidence of clinical inertia when comparing outpatient to inpatient regimens, when evaluating daily changes in management, and when evaluating responses to previous hyperglycemia. Finally, we demonstrated that use of an insulin sliding scale by itself was associated with worse glycemic control after extensive adjustment for a variety of clinical factors.

Of note, other than the use of sliding‐scale insulin by itself, we could not find a relationship between specific daily adjustments to insulin orders and daily glycemic control in this study. However, we did find differences in glycemic control by medical team and by floor (the latter a proxy for nursing staff). This suggests that glycemic control depends on the exact details of how insulin is managed, rather than on crude measures of insulin adjustment such as change in dose in response to hyperglycemia. These findings also suggest that interventions focused on medical and nursing staff may be able to improve inpatient glycemic control.

The association between the use of oral diabetic agents and improved glucose control was notable and could represent an actual benefit of these agents (especially when added to sliding‐scale insulin by itself) and/or the result of uncontrolled confounding (ie, as a marker of well‐controlled diabetes). Further study is needed to distinguish among these possibilities.

Previous studies have shown evidence of poor inpatient glycemic control as well as the deleterious effects of sliding‐scale insulin by itself.8 This study is perhaps most notable for the suggestion that little, if anything, has changed over the previous decade in this area, despite recent well‐done observational and randomized controlled trials demonstrating the hazards of inpatient hyperglycemia and the publication of expert consensus statements on inpatient glucose management. Strategies to improve glucose control have been investigated to a greater extent in intensive care units12, 13 than on general medical wards,14 perhaps because the strength of evidence is strongest in this setting. Without such strong evidence for general medical patients, factors such as clinician fear of hypoglycemia, clinical inertia, and resistance to institutional change may play predominant roles.

Clinical inertia (ie, recognition of the problem but failure to act)15 has been demonstrated previously in the outpatient management of diabetes16, 17; this study provides evidence of the phenomenon in the inpatient setting. Work by Phillips and colleagues15 has shown that clinical inertia results from at least 3 problems: overestimation of care provided; use of soft reasons to avoid intensification of therapy; and lack of education, training, and practice organization aimed at achieving specific goals. All 3 problems likely contribute to clinical inertia in inpatient diabetes management. Revised educational programs; systems for improving care such as reminders, flow sheets, and order sets; and performance feedback can help address clinical inertia and improve care.15

This study should be viewed in light of its limitations, including relatively small sample size, thus limiting our ability to detect other possible significant predictors of glycemic control, and the use of a single institution, thus limiting generalizability. However, recent data from the University HealthSystem Consortium revealed that our institution was typical of the 37 participating academic medical centers in that study.18 In addition, only 9 patients were identified without a prior diagnosis of diabetes, raising the possibility that some patients with undiagnosed diabetes were missed in our study. However, our search strategy included a daily review of automatically abstracted laboratory values, making this possibility less likely. Strengths of this study include its prospective data collection methods with rigorous inclusion criteria, collection of detailed clinical data, and use of a novel statistical technique to more accurately assess the complex relationship between insulin use and glycemic control, appropriately adjusting for confounding by indication caused by prior glucose measurements.

Future research should focus on patient, clinician, and system barriers to improving inpatient glycemic management, using the clinical inertia framework as a starting point, and on the creation of insulin protocols that can be used and proven effective in the non‐ICU inpatient setting. Also needed are improved measures of the quality of glycemic control, insulin orders, and daily insulin adjustment.

In conclusion, inpatient glycemic management was shown to be in need of improvement. Institutionwide quality improvement efforts should probably target both physician and nursing behavior and should focus on increasing use of basal and nutritional insulin, as proposed in recent guidelines, avoiding use of sliding‐scale insulin by itself, and performing daily insulin adjustment in response to previous hypo‐ or hyperglycemia. Hospitalists can play a major role in these institutionwide quality improvement efforts.

Diabetes mellitus is a common comorbidity of hospitalization; in 2003 diabetes was a secondary diagnosis in 17.8% of all adult hospital discharges.1 When undiagnosed diabetes is included, the prevalence of inpatient diabetes or hyperglycemia may be as high as 38%.2 Recent studies show that hyperglycemia in hospitalized patients complicates numerous illnesses and is an independent predictor of adverse outcomes.3 Treatment of inpatient hyperglycemia improves outcomes, including mortality, for patients in surgical intensive care units4 and possibly for those admitted for myocardial infarction.5, 6 For these reasons, the American Diabetes Association and the American College of Endocrinology now recommend that glucose levels of all patients admitted to non‐critical‐care units be maintained below 180 mg/dL.3, 7

Evidence‐based recommendations for achieving these goals include effective protocols for subcutaneous insulin therapy for patients who do not require continuous intravenous insulin infusion. Components of these protocols include use of basal insulin and scheduled nutritional insulin, avoiding use of supplemental (sliding‐scale) insulin alone (which has been shown to be ineffective and possibly deleterious in prior studies),8 and adjustment of insulin orders to reflect nutritional intake, insulin sensitivity, and previous response to therapy.7

We conducted this study to evaluate the current state of glycemic control and adherence to current recommendations on a general medicine service run by hospitalists in a busy teaching hospital. We also sought to correlate insulin‐ordering practices with the quality of glycemic control in these patients.

METHODS

RESULTS

We prospectively identified 123 patients for the study. Subsequently, 16 patients were excluded, 11 who did not have diabetes or inpatient hyperglycemia (most of whom had been placed on insulin prophylactically to avoid steroid‐induced hyperglycemia), 2 who were admitted for diabetic ketoacidosis, 2 who were not on GMS teams 13, and 1 whose data could not be accessed. Characteristics of the remaining 107 study subjects are shown in Table 1. The mean age of the subjects was 65.2 years; 55% were men. Nine patients had no previous diagnosis of diabetes, 43% were taking insulin prior to admission, 14% had severe diabetic complications, and the median HbA_1C was 7.

Regarding insulin‐ordering practices (Table 2), 47 patients (43%) had basal insulin prescribed, while 4% of patients had an order for scheduled mealtime short‐ or rapid‐acting insulin. Of the 89 patients on sliding‐scale insulin, 80 (90%) had orders written for the default sliding scale built into the computerized physician order entry system at BWH. There was no correlation between intensity of the sliding scale and the patient's total daily insulin dose (data not shown). Of the patients on sliding‐scale insulin, 47% were prescribed basal insulin, 39% were prescribed oral agents, and 23% were prescribed neither.

Regarding glucose control, 317 of 1022 glucose meter readings (31%) were greater than 180 mg/dL, and the mean rate of glucose readings greater than 180 mg/dL per patient was also 31%. Approximately three quarters of all patients had at least one routine glucose reading greater than 180 mg/dL, and 35% of patients had at least 40% of their routine glucose readings greater than 180 mg/dL (Table 2). Twelve of 1022 readings (1.2%) were less than 60 mg/dL, and 11% of patients had at least one glucose reading less than 60 mg/dL (Table 2).

Despite a relatively constant percentage of glucose readings greater than 180 mg/dL per patient over the first 5 days of hospitalization (25%36% each day), we found no evidence of change in the percentage of patients prescribed basal insulin or the percentage of insulin given as basal insulin, and there was a small but significant increase in the total amount of insulin prescribed (Table 3). Of the 75 patients with at least one episode of hypo‐ or hyperglycemia, 43 (57%) were ever prescribed basal insulin, 29 (39%) were prescribed oral diabetes agents, and only 26 (35%) had any change to their insulin regimen during the first 5 days of their hospitalization on GMS. Of the 47 patients prescribed basal insulin in the hospital, 41 had been taking insulin prior to admission.

In a multivariable analysis of the mean glucose reading per patient‐day, we found several predictors of lower glucose readings, including diet‐controlled diabetes prior to admission and prescription of oral hypoglycemic medications in the hospital. We also found several predictors of higher glucose readings, including severe diabetic complications and higher glucose level at admission. Finally, we noted variation both by medical team (each composed of 1 medical attending, 1 resident, and 2 interns) and by floor of the hospital (each staffed by a different cadre of nurses). Adjusting for these factors (as well as for the daily use of dextrose‐containing intravenous fluids and steroids, sex, age, Charlson comorbidity score, APACHE 3 score, prior diagnosis of diabetes, HbA_1C level, and length of hospital stay) use of sliding‐scale insulin alone (eg, without scheduled basal or nutritional insulin) was associated with a daily average glucose reading that was 20 mg/dL higher than that for those prescribed scheduled insulin or those not prescribed a sliding scale at all (95% confidence interval, 5.035 mg/dL; Table 4). In a separate analysis, adjusting for the same clinical factors, we could find no relationship between change in daily dose of basal insulin and change in daily average glucose level (data not shown).

DISCUSSION

In this observational study, we found several deficiencies in the management of diabetes and hyperglycemia among hospitalized patients on a hospitalist‐run general medical service. These deficiencies were both in processes of care (eg, limited use of basal and especially nutritional insulin) and in outcomes (ie, glycemic control) compared with national guidelines. We also found evidence of clinical inertia when comparing outpatient to inpatient regimens, when evaluating daily changes in management, and when evaluating responses to previous hyperglycemia. Finally, we demonstrated that use of an insulin sliding scale by itself was associated with worse glycemic control after extensive adjustment for a variety of clinical factors.

Of note, other than the use of sliding‐scale insulin by itself, we could not find a relationship between specific daily adjustments to insulin orders and daily glycemic control in this study. However, we did find differences in glycemic control by medical team and by floor (the latter a proxy for nursing staff). This suggests that glycemic control depends on the exact details of how insulin is managed, rather than on crude measures of insulin adjustment such as change in dose in response to hyperglycemia. These findings also suggest that interventions focused on medical and nursing staff may be able to improve inpatient glycemic control.

The association between the use of oral diabetic agents and improved glucose control was notable and could represent an actual benefit of these agents (especially when added to sliding‐scale insulin by itself) and/or the result of uncontrolled confounding (ie, as a marker of well‐controlled diabetes). Further study is needed to distinguish among these possibilities.

Previous studies have shown evidence of poor inpatient glycemic control as well as the deleterious effects of sliding‐scale insulin by itself.8 This study is perhaps most notable for the suggestion that little, if anything, has changed over the previous decade in this area, despite recent well‐done observational and randomized controlled trials demonstrating the hazards of inpatient hyperglycemia and the publication of expert consensus statements on inpatient glucose management. Strategies to improve glucose control have been investigated to a greater extent in intensive care units12, 13 than on general medical wards,14 perhaps because the strength of evidence is strongest in this setting. Without such strong evidence for general medical patients, factors such as clinician fear of hypoglycemia, clinical inertia, and resistance to institutional change may play predominant roles.

Clinical inertia (ie, recognition of the problem but failure to act)15 has been demonstrated previously in the outpatient management of diabetes16, 17; this study provides evidence of the phenomenon in the inpatient setting. Work by Phillips and colleagues15 has shown that clinical inertia results from at least 3 problems: overestimation of care provided; use of soft reasons to avoid intensification of therapy; and lack of education, training, and practice organization aimed at achieving specific goals. All 3 problems likely contribute to clinical inertia in inpatient diabetes management. Revised educational programs; systems for improving care such as reminders, flow sheets, and order sets; and performance feedback can help address clinical inertia and improve care.15

This study should be viewed in light of its limitations, including relatively small sample size, thus limiting our ability to detect other possible significant predictors of glycemic control, and the use of a single institution, thus limiting generalizability. However, recent data from the University HealthSystem Consortium revealed that our institution was typical of the 37 participating academic medical centers in that study.18 In addition, only 9 patients were identified without a prior diagnosis of diabetes, raising the possibility that some patients with undiagnosed diabetes were missed in our study. However, our search strategy included a daily review of automatically abstracted laboratory values, making this possibility less likely. Strengths of this study include its prospective data collection methods with rigorous inclusion criteria, collection of detailed clinical data, and use of a novel statistical technique to more accurately assess the complex relationship between insulin use and glycemic control, appropriately adjusting for confounding by indication caused by prior glucose measurements.

Future research should focus on patient, clinician, and system barriers to improving inpatient glycemic management, using the clinical inertia framework as a starting point, and on the creation of insulin protocols that can be used and proven effective in the non‐ICU inpatient setting. Also needed are improved measures of the quality of glycemic control, insulin orders, and daily insulin adjustment.

In conclusion, inpatient glycemic management was shown to be in need of improvement. Institutionwide quality improvement efforts should probably target both physician and nursing behavior and should focus on increasing use of basal and nutritional insulin, as proposed in recent guidelines, avoiding use of sliding‐scale insulin by itself, and performing daily insulin adjustment in response to previous hypo‐ or hyperglycemia. Hospitalists can play a major role in these institutionwide quality improvement efforts.