Citations

Tear glucose sensing for diabetes management has long been sought as an alternative to more invasive self-monitoring of blood glucose (SMBG).

Objective: The objective was to assess processes of care for patients with diabetes undergoing elective surgery. Methods: A retrospective review of medical records was conducted to determine frequency of perioperative glucose monitoring, changes in glucose control, and treatment of intraoperative hyperglycemia. Results: A total of 268 patients underwent 287 elective procedures. Mean age was 67 years, 63% were men, 97% had type 2 diabetes, and most (57%) were treated with oral hypoglycemic agents. Average perioperative time was approximately 8 h. Mean preoperative hemoglobin A1c was 7.0%; however, this value was checked in only 52% of cases. A glucose measurement was obtained in 89% of cases in the preoperative area and in 87% in the postanesthesia care unit, but in only 33% of cases did a value get checked intraoperatively. Average glucose was 139 mg/dl preoperatively, increasing to 166 mg/dl postoperatively ( p <.001). Glucose levels increased regardless of type of outpatient medical therapy used to treat hyperglycemia, except for those on combination oral agents plus insulin ( p =.06). Conclusions: These data indicate suboptimal documentation of outpatient hemoglobin A1c. Intraoperative glucose monitoring seldom occurred, despite prolonged periods under anesthesia and perioperative deterioration of glycemic control. Standards need to be developed and interventions are needed to enhance management of diabetes patients undergoing elective procedures.

Objective: Our objective was to assess the application of insulin regimens in surgical postoperative patients with diabetes. Methods: A chart review was conducted of patients with diabetes who were hospitalized postoperatively between January 1 and April 30, 2011. Analysis was restricted to patients hospitalized for ≥3 days and excluded cases with an endocrinology consult. Insulin regimens were categorized as “basal plus short acting,” “short acting only,” or “none,” and the pattern of use was evaluated by hyperglycemia severity according to tertiles of both mean glucose and the number of glucose measurements >180 mg/dl. Results: Among cases selected for analysis ( n = 119), examination of changes in insulin use based on tertiles of mean glucose showed that use of basal plus short-acting insulin increased from 10% in the lowest tertile (mean glucose, 120 mg/dl) to 18% in the highest tertile (mean glucose, 198 mg/dl; p < .01); however, 70% of patients in the highest tertile continued to receive short-acting insulin only, with 12% receiving no insulin. Intensification of insulin to a basal plus short-acting regimen was also seen when changes were evaluated by the number of measurements >180 mg/dl ( p < .01), but 70% and 12% of patients in the highest tertile still remained only on short-acting insulin or received no insulin, respectively. Conclusions: Use of basal plus short-acting insulin therapy increased with worsening hyperglycemia, but many cases did not have therapy intensified to the recommended insulin regimen—evidence of clinical inertia. Strategies should be devised to overcome inpatient clinical inertia in the treatment of postoperative patients with diabetes.

Background: We aim to provide data on a diabetes technology simulation course (DTSC) that instructs internal medicine residents in the use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring system (CGMS) devices. Methods: The DTSC was implemented during calendar year 2012 and conducted in the institution's simulation center. It consisted of a set of prerequisites, a practicum, and completion of a web-based inpatient CSII-ordering simulation. DTSC participants included only those residents in the outpatient endocrinology rotation. Questionnaires were used to determine whether course objectives were met and to assess the satisfaction of residents with the course. Questionnaires were also administered before and after the endocrine rotation to gauge improvement in familiarity with CSII and CGMS technologies. Results: During the first year, 12 of 12 residents in the outpatient endocrinology rotation completed the DTSC. Residents reported that the course objectives were fully met. The mean satisfaction score with the course ranged from 4.0 to 4.9 (maximum, 5), with most variables rated above 4.5. Self-reported familiarity with the operation of CSII and CGMS devices increased significantly in the postrotation survey compared with that on the prerotation survey (both p < .01). Conclusions: In this pilot program, simulation-based education increased the perceived familiarity of residents with CSII and CGMS technologies. In light of these preliminary findings, the course will continue to be offered, with further data accrual. Future work will involve piloting the DTSC approach among other types of providers, such as residents in other specialties or inpatient nursing staff.

Quantitative scores fail to capture all important features of learner performance. This awareness has led to increased use of qualitative data when assessing health professionals. Yet the use of qualitative assessments is hampered by incomplete understanding of their role in forming judgments, and lack of consensus in how to appraise the rigor of judgments therein derived. The authors articulate the role of qualitative assessment as part of a comprehensive program of assessment, and translate the concept of validity to apply to judgments arising from qualitative assessments. They first identify standards for rigor in qualitative research, and then use two contemporary assessment validity frameworks to reorganize these standards for application to qualitative assessment. Standards for rigor in qualitative research include responsiveness, reflexivity, purposive sampling, thick description, triangulation, transparency, and transferability. These standards can be reframed using Messick’s five sources of validity evidence (content, response process, internal structure, relationships with other variables, and consequences) and Kane’s four inferences in validation (scoring, generalization, extrapolation, and implications). Evidence can be collected and evaluated for each evidence source or inference. The authors illustrate this approach using published research on learning portfolios. The authors advocate a “methods-neutral” approach to assessment, in which a clearly stated purpose determines the nature of and approach to data collection and analysis. Increased use of qualitative assessments will necessitate more rigorous judgments of the defensibility (validity) of inferences and decisions. Evidence should be strategically sought to inform a coherent validity argument.