Discontinuation of Antihyperglycemic Therapy After Acute Myocardial Infarction: Medical Necessity or Medical Error?
Discontinuation of Antihyperglycemic Therapy After Acute Myocardial Infarction: Medical Necessity or Medical Error?
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DOI：
10.1016/s1553-7250(12)38051-3
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发表时间：
2012-09-01
影响因子：
2.3
通讯作者：
Inzucchi, Silvio E.
中科院分区：
文献类型：
--
作者：
Lovig, Kay O.;Horwitz, Leora;Inzucchi, Silvio E.
背景：国家医疗保险数据库显示，每八名老年糖尿病患者中就有一人在急性心肌梗死(AMI)后停止了所有抗高血糖治疗(AHT)。这种做法与一年死亡率的增加有关，但停止AHT的原因尚不清楚。进行了一项研究，以确定这种做法可能是由于医疗需要(即新的禁忌症)或疏忽-在这种情况下，可能存在质量改进的机会。方法：确定了约327名糖尿病患者，他们在一年的时间里因急性心肌梗死而在学术医学中心和附属社区医院住院。对217例以急性心肌梗死为主要诊断的急性心肌梗死患者进行了详细的图表回顾，这些患者接受了AHT(胰岛素，81)治疗。25例患者(11.5%)出院，其中24例(96%)在医院接受了AHT治疗，多为胰岛素滑动评分。一名患者(4%)的AHT因为护理目标的改变而停止，第二名患者出现复发性低血糖，第三名患者在AHT停止后住院期间血糖完全正常。其余22名患者(88%)被归类为无正当理由出院。除左心室射血分数(LVEF)较好外，接受AHT治疗和不接受AHT治疗的患者的人口学/临床特征相似。结论：糖尿病患者在急性心肌梗死后AHT治疗后出院的百分比与国家数据库中的比例(约八分之一)几乎相同。在近90%的病例中找不到这种做法的明确原因，这表明对于越来越多的患有缺血性心脏病的糖尿病患者来说，这可能经常构成医疗错误。
Background: A national Medicare database indicated that one in eight older patients with diabetes was discharged off all antihyperglycemic therapy (AHT) following acute myocardial infarction (AMI). This practice was associated with increased one-year mortality, but the reasons for stopping AHT were not known. A study was conducted to determine whether such practice might be due to medical necessity (that is, a new contraindication) or oversight-in which case a quality improvement opportunity might exist.Methods: Some 327 diabetic patients were identified who were hospitalized with AMI during a one-year period at an academic medical center and an affiliated community hospital. Detailed chart reviews were conducted on the 217 patients with AMI as a principal diagnosis who were admitted on AHT (insulin, 81). Twenty-five patients (11.5%) were discharged off AHT, 24 (96%) of whom received some AHT in the hospital, mostly as insulin sliding scale. One patient's (4%) AHT was stopped because of a change in care goals, a second developed recurrent hypoglycemia, and a third had entirely normal in-hospital blood glucose after AHT discontinuation. The remaining 22 patients (88%) were categorized as being discharged off AHT without justification. The demographic/clinical characteristics of those discharged on versus off AHT were similar, except for better left ventricular ejection fraction (LVEF) in the latter.Conclusions: The percentage of diabetic patients discharged off AHT following AMI was nearly identical to that in a national database (approximately one out of eight). No clear reason for this practice could be found in nearly 90% of the cases, suggesting that it may often constitute a medical error for a growing population of diabetic patients with ischemic heart disease.