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Inpatient Glucose Values: Determining the Nondiabetic Range and Use in Identifying Patients at High Risk for Diabetes

  • Mary K. Rhee
    Correspondence
    Requests for reprints should be addressed to Mary Rhee, MD, MSCR, Atlanta VA Medical Center, Medical Subspecialty/Endocrinology, Room 6C 115D, 1670 Clairmont Road, Decatur, GA 30033.
    Affiliations
    Medical Subspecialty/Endocrinology, Atlanta VA Medical Center, Decatur, Ga

    Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Ga
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  • Sandra E. Safo
    Affiliations
    Medical Subspecialty/Endocrinology, Atlanta VA Medical Center, Decatur, Ga

    Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Ga
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  • Sandra L. Jackson
    Affiliations
    Medical Subspecialty/Endocrinology, Atlanta VA Medical Center, Decatur, Ga

    Nutrition and Health Sciences, Graduate Division of Biological and Biomedical Sciences, Emory University, Atlanta, Ga

    Division of Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga
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  • Wenqiong Xue
    Affiliations
    Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Ga

    Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Conn
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  • Darin E. Olson
    Affiliations
    Medical Subspecialty/Endocrinology, Atlanta VA Medical Center, Decatur, Ga

    Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Ga
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  • Qi Long
    Affiliations
    Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Ga

    Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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  • Diana Barb
    Affiliations
    Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Ga

    Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Gainesville
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  • J. Sonya Haw
    Affiliations
    Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Ga
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  • Anne M. Tomolo
    Affiliations
    Medical Subspecialty/Endocrinology, Atlanta VA Medical Center, Decatur, Ga

    Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, Ga
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  • Lawrence S. Phillips
    Affiliations
    Medical Subspecialty/Endocrinology, Atlanta VA Medical Center, Decatur, Ga

    Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Ga
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Published:October 06, 2017DOI:https://doi.org/10.1016/j.amjmed.2017.09.021

      Abstract

      Background

      Many individuals with diabetes remain undiagnosed, leading to delays in treatment and higher risk for subsequent diabetes complications. Despite recommendations for diabetes screening in high-risk groups, the optimal approach is not known. We evaluated the utility of inpatient glucose levels as an opportunistic screening tool for identifying patients at high risk for diabetes.

      Methods

      We retrospectively examined 462,421 patients in the US Department of Veterans Affairs healthcare system, hospitalized on medical/surgical services in 2000-2010, for ≥3 days, with ≥2 inpatient random plasma glucose (RPG) measurements. All had continuity of care: ≥1 primary care visit and ≥1 glucose measurement within 2 years before hospitalization and yearly for ≥3 years after discharge. Glucose levels during hospitalization and incidence of diabetes within 3 years after discharge in patients without diabetes were evaluated.

      Results

      Patients had a mean age of 65.0 years, body mass index of 29.9 kg/m2, and were 96% male, 71% white, and 18% black. Pre-existing diabetes was present in 39.4%, 1.3% were diagnosed during hospitalization, 8.1% were diagnosed 5 years after discharge, and 51.3% were never diagnosed (NonDM). The NonDM group had the lowest mean hospital RPG value (112 mg/dL [6.2 mmol/L]). Having at least 2 RPG values >140 mg/dL (>7.8 mmol/L), the 95th percentile of NonDM hospital glucose, provided 81% specificity for identifying incident diabetes within 3 years after discharge.

      Conclusions

      Screening for diabetes could be considered in patients with at least 2 hospital glucose values at/above the 95th percentile of the nondiabetic range (141 mg/dL [7.8 mmol/L]).

      Keywords

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      References

        • Aubert R.E.
        • Geiss L.S.
        • Ballard D.J.
        • Beth C.
        • Herman W.H.
        Diabetes-related hospitalization and hospital utilization.
        in: Diabetes in America. National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, Md1995: 553-563
        • Centers for Disease Control and Prevention
        Diagnosed diabetes.
        (Available at:)
        • Menke A.
        • Casagrande S.
        • Geiss L.
        • Cowie C.C.
        Prevalence of and trends in diabetes among adults in the United States, 1988-2012.
        JAMA. 2015; 314: 1021-1029
        • Centers for Disease Control and Prevention, US Department of Health and Human Services
        National Diabetes Statistics Report.
        CDC, Atlanta, Ga2017
        • Boyle J.P.
        • Honeycutt A.A.
        • Narayan K.M.
        • et al.
        Projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the U.S.
        Diabetes Care. 2001; 24: 1936-1940
        • Gregg E.W.
        • Cadwell B.L.
        • Cheng Y.J.
        • et al.
        Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the U.S.
        Diabetes Care. 2004; 27: 2806-2812
        • Nathan D.M.
        • Group D.E.R.
        The diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview.
        Diabetes Care. 2014; 37: 9-16
        • Holman R.R.
        • Paul S.K.
        • Bethel M.A.
        • Matthews D.R.
        • Neil H.A.
        10-year follow-up of intensive glucose control in type 2 diabetes.
        N Engl J Med. 2008; 359: 1577-1589
        • American Diabetes Association
        2. Classification and diagnosis of diabetes.
        Diabetes Care. 2016; 39: S13-S22
        • Siu A.L.
        • US Preventive Services Task Force
        Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive services task force recommendation statement.
        Ann Intern Med. 2015; 163: 861-868
        • Simmons R.K.
        • Echouffo-Tcheugui J.B.
        • Sharp S.J.
        • et al.
        Screening for type 2 diabetes and population mortality over 10 years (ADDITION-Cambridge): a cluster-randomised controlled trial.
        Lancet. 2012; 380: 1741-1748
        • Lankisch M.
        • Futh R.
        • Gulker H.
        • et al.
        Screening for undiagnosed diabetes in patients with acute myocardial infarction.
        Clin Res Cardiol. 2008; 97: 753-759
        • Knudsen E.C.
        • Seljeflot I.
        • Abdelnoor M.
        • et al.
        Abnormal glucose regulation in patients with acute ST-elevation myocardial infarction-a cohort study on 224 patients.
        Cardiovasc Diabetol. 2009; 8: 6
        • Norhammar A.
        • Tenerz A.
        • Nilsson G.
        • et al.
        Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study.
        Lancet. 2002; 359: 2140-2144
        • Charfen M.A.
        • Ipp E.
        • Kaji A.H.
        • Saleh T.
        • Qazi M.F.
        • Lewis R.J.
        Detection of undiagnosed diabetes and prediabetic states in high-risk emergency department patients.
        Acad Emerg Med. 2009; 16: 394-402
        • Ginde A.A.
        • Cagliero E.
        • Nathan D.M.
        • Camargo Jr, C.A.
        Point-of-care glucose and hemoglobin A1c in emergency department patients without known diabetes: implications for opportunistic screening.
        Acad Emerg Med. 2008; 15: 1241-1247
        • Gray C.S.
        • Scott J.F.
        • French J.M.
        • Alberti K.G.
        • O'Connell J.E.
        Prevalence and prediction of unrecognised diabetes mellitus and impaired glucose tolerance following acute stroke.
        Age Ageing. 2004; 33: 71-77
        • American Diabetes Association
        Standards of medical care in diabetes.
        Diabetes Care. 2004; 27: S15-S35
        • Phillips L.S.
        • Ziemer D.C.
        • Kolm P.
        • et al.
        Glucose challenge test screening for prediabetes and undiagnosed diabetes.
        Diabetologia. 2009; 52: 1798-1807
        • Ziemer D.C.
        • Kolm P.
        • Foster J.K.
        • et al.
        Random plasma glucose in serendipitous screening for glucose intolerance: screening for impaired glucose tolerance study 2.
        J Gen Intern Med. 2008; 23: 528-535
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Dungan K.M.
        • Braithwaite S.S.
        • Preiser J.C.
        Stress hyperglycaemia.
        Lancet. 2009; 373: 1798-1807
        • Marik P.E.
        • Bellomo R.
        Stress hyperglycemia: an essential survival response!.
        Crit Care. 2013; 17: 305
        • Pottie K.
        • Jaramillo A.
        • et al.
        • Canadian Task Force on Preventive Health C
        Recommendations on screening for type 2 diabetes in adults.
        CMAJ. 2012; 184: 1687-1696
        • Chatterjee R.
        • Narayan K.M.
        • Lipscomb J.
        • et al.
        Screening for diabetes and prediabetes should be cost-saving in patients at high risk.
        Diabetes Care. 2013; 36: 1981-1987
        • Olson D.E.
        • Zhu M.
        • Long Q.
        • et al.
        Increased cardiovascular disease, resource use, and costs before the clinical diagnosis of diabetes in veterans in the Southeastern U.S.
        J Gen Intern Med. 2015; 30: 749-757
        • Ziemer D.C.
        • Kolm P.
        • Weintraub W.S.
        • et al.
        Age, BMI, and race are less important than random plasma glucose in identifying risk of glucose intolerance: the Screening for Impaired Glucose Tolerance Study (SIGT 5).
        Diabetes Care. 2008; 31: 884-886
        • Bowen M.E.
        • Xuan L.
        • Lingvay I.
        • Halm E.A.
        Performance of a random glucose case-finding strategy to detect undiagnosed diabetes.
        Am J Prev Med. 2017; 52: 710-716
        • McAllister D.A.
        • Hughes K.A.
        • Lone N.
        • et al.
        Stress hyperglycaemia in hospitalised patients and their 3-year risk of diabetes: a Scottish retrospective cohort study.
        PLoS Med. 2014; 11: e1001708
        • Nanayakkara N.
        • Nguyen H.
        • Churilov L.
        • et al.
        Inpatient HbA1c testing: a prospective observational study.
        BMJ Open Diabetes Res Care. 2015; 3: e000113
        • Chatterjee R.
        • Narayan K.M.
        • Lipscomb J.
        • Phillips L.S.
        Screening adults for pre-diabetes and diabetes may be cost-saving.
        Diabetes Care. 2010; 33: 1484-1490
        • Twombly J.G.
        • Long Q.
        • Zhu M.
        • et al.
        Validity of the primary care diagnosis of diabetes in veterans in the southeastern United States.
        Diabetes Res Clin Pract. 2011; 91: 395-400
        • Miller D.R.
        • Safford M.M.
        • Pogach L.M.
        Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data.
        Diabetes Care. 2004; 27: B10-B21