Increased Glycemic Variability Is Independently Associated With Length of Stay and Mortality in Noncritically Ill Hospitalized Patients
Mendez, Carlos E.; Mok, Ki-Tae; Ata, Ashar; Tanenberg, Robert J.; Calles-Escandon, Jorge; Umpierrez, Guillermo E.
OBJECTIVE To investigate the association between glycemic variability (GV) and both length of stay (LOS) and 90-day mortality in noncritically ill hospitalized patients. RESEARCH DESIGN AND METHODS This study retrospectively analyzed 4,262 admissions to the general medicine or surgery services during a 2 year period. Patients with point-of-care glucose monitoring and a minimum of two glucose values per day on average were selected. GV was assessed by SD and coefficient of variation (CV). Data were analyzed with linear and logistic multivariate regression analysis in separate models for SD and CV. Analysis was performed with generalized estimating equations to adjust for correlation between multiple admissions in some individual cases. RESULTS After exclusions, 935 admissions comprised the sample. Results of adjusted analysis indicate that for every 10 mg/dL increase in SD and 10–percentage point increase in CV, LOS increased by 4.4 and 9.7%, respectively. Relative risk of death in 90 days also increased by 8% for every 10-mg/dL increase in SD. These associations were independent of age, race, service of care (medicine or surgery), previous diagnosis of diabetes, HbA1c, BMI, the use of regular insulin as a sole regimen, mean glucose, and hypoglycemia occurrence during the hospitalization. CONCLUSIONS Our results indicate that increased GV during hospitalization is independently associated with longer LOS and increased mortality in noncritically ill patients. Prospective studies with continuous glucose monitoring are necessary to investigate this association thoroughly and to generate therapeutic strategies targeted at decreasing GV. Inpatient hyperglycemia is common, and it has been associated with increased morbidity and mortality in patients with and without diabetes (1–7). In the intensive care unit (ICU) setting, hypoglycemia has also been independently associated with a significant increase in mortality (8–10). Recently, a third metric of glucose control, known as glycemic variability (GV), has been proposed to be additionally implicated in the disease-associated process of dysglycemia (11). GV refers to fluctuations of blood glucose values around the mean and has been posited as a novel marker for poor glycemic control (12,13). In vitro and human studies suggest that high GV leads to greater oxidative stress than does sustained hyperglycemia (14,15). Studies of ICU patients have consistently demonstrated that increased GV is independently associated with higher mortality (16–19). Notably, results from a large multicenter study concluded that GV was a stronger predictor of ICU mortality than was mean glucose concentrations (20). Although there is no consensus as to the best method to determine GV in hospitalized patients, the use of SD of glucose values has been well validated by previous ICU studies (16,20). Coefficient of variation (CV) has also been suggested as a strong independent index for measuring GV because it corrects for mean glucose levels (21,22). Despite substantial scientific evidence from the ICU, no previous studies have investigated the association between GV and clinical outcomes in patients admitted to the general medical and surgical wards. The purpose of this study was therefore to investigate the association between GV and length of stay (LOS) and 90-day mortality in noncritically ill hospitalized patients. We hypothesize that increased GV in this setting is associated with increased LOS and mortality.
Mendez, Carlos E., & Mok, Ki-Tae, & Ata, Ashar, & Tanenberg, Robert J., & Calles-Escandon, Jorge, & Umpierrez, Guillermo E.. (December 2013). Increased Glycemic Variability Is Independently Associated With Length of Stay and Mortality in Noncritically Ill Hospitalized Patients. Diabetes Care, 36(12), 4091- 4097. Retrieved from http://hdl.handle.net/10342/5516
Mendez, Carlos E., and Mok, Ki-Tae, and Ata, Ashar, and Tanenberg, Robert J., and Calles-Escandon, Jorge, and Umpierrez, Guillermo E.. "Increased Glycemic Variability Is Independently Associated With Length of Stay and Mortality in Noncritically Ill Hospitalized Patients". Diabetes Care. 36:12. (4091-4097), December 2013. October 20, 2018. http://hdl.handle.net/10342/5516.
Mendez, Carlos E. and Mok, Ki-Tae and Ata, Ashar and Tanenberg, Robert J. and Calles-Escandon, Jorge and Umpierrez, Guillermo E., "Increased Glycemic Variability Is Independently Associated With Length of Stay and Mortality in Noncritically Ill Hospitalized Patients," Diabetes Care 36, no. 12 (December 2013), http://hdl.handle.net/10342/5516 (accessed October 20, 2018).
Mendez, Carlos E., Mok, Ki-Tae, Ata, Ashar, Tanenberg, Robert J., Calles-Escandon, Jorge, Umpierrez, Guillermo E.. Increased Glycemic Variability Is Independently Associated With Length of Stay and Mortality in Noncritically Ill Hospitalized Patients. Diabetes Care. December 2013; 36(12): 4091-4097. http://hdl.handle.net/10342/5516. Accessed October 20, 2018.