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The Association between blood glucose and length of hospital
stay due to Acute COPD exacerbation
Yusuf Kasirye, Melissa Simpson, Naren Epperla, Steven Yale
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Blood glucose and acute COPD Blood glucose and acute COPD exacerbationsexacerbations
● Introduction● Methods● Results● Discussion
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IntroductionIntroduction
● Chronic Obstructive Pulmonary Disease (COPD) is the fourth most common cause of death in the United States, affecting ~ 24 million people
● Several studies have looked at hospitalizations due to acute COPD exacerbations (AECOPD) and comorbidities such as diabetes mellitus and metabolic syndrome
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● Two studies of hospital admissions found a marginal association between DM and length of hospital stay
● Did not examine blood glucose levels
● Another study found that increased blood glucose is associated with longer hospitalization
● Analyzed highest inpatient BG value only● Looked at length of stay as <9 days (good) compared to
≥ 9 days (bad)
IntroductionIntroduction
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IntroductionIntroduction
● The purpose of this study is to examine the association between inpatient blood glucose (BG) levels and the following clinical outcomes in patients hospitalized for AECOPD:
● In hospital complications● Length of hospitalization ● Thirty day re-hospitalization (all cause)● Ninety day mortality (all cause)
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MethodsMethods
●Retrospective cohort of 209 patients hospitalized for AECOPD (physician validated) from 1-1-2—4 to 12-31-2008 at St. Joseph’s hospital (Marshfield WI)● Inclusion criteria:●COPD diagnosis (according to GOLD criteria) at some point
prior to index hospitalization●AECOPD diagnosis at admission and discharge●A BG measurement within 6 hours of hospitalization●≥ 2 BG measurements during hospitalization (analyzed
both fasting and random blood glucose measurements)
Study population and design
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MethodsMethods
●In-hospital complications: the presence of cardiac, respiratory, neurologic, renal, or septic complications during index hospitalization ●Length of hospital stay: the time from admission
until discharge from hospital, measured in days ●Thirty day readmission: hospitalization for any
cause within 30 days of the discharge date of index hospitalization●Ninety day all cause mortality: death due to any
cause within 90 days of index hospitalization
Outcomes
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MethodsMethods●Outcomes modeled as follows:
●LOS: analyzed both as a discrete and categorical (≤2 days vs. > 2 days) outcome
●Thirty day readmission: analyzed as a categorical outcome●Ninety day all-cause mortality: analyzed as a categorical outcome.
●Blood glucose was analyzed as a continuous variable and was calculated as mean per day (ng/ml), odds ratios reported for a 100 ng/ml decrease in BG
●Logistic regression analyses accounting for repeated BG measurement during hospitalization were used for odds ratio estimation (SAS, proc genmod, Cary NC)●Age and DM were forced into adjusted models, other covariates were
included if they had a significance level of ≤ 0.05 or changed the beta estimate for BG by ≥ 10%
Statistical analysis
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ResultsResultsIn-hospital complications
Complications during index
hospitalization
No Complications during index
hospitalization Univariate analysis Adjusted analysisCharacteristic: n = 24 n = 185 OR 95% CI p-value OR 95% CI p-valueBlood glucose (100 ng/ml decrease in daily mean) 1.81 0.81-4.05 0.15 1.81 0.95-3.47 0.07
Age (years) at hospital admission - mean (±sd) 67.3(9.5) 64.5(8.1) 1.05 0.99-1.11 0.12 1.08 0.97-1.19 0.15Diabetes Mellitus at hospital admission - n(%) 7(29) 56(30) 0.95 0..37-2.42 0.91 1.06 0.37-3.07 0.92Male sex - n(%) 7(29) 73(39) 0.63 0.25-1.60 0.33Corticosteroids given within 24 hours of hospitalization - n(%) 0(0) 176(96) *Current smoker - n(%) 75(41) 110(59) 0.73 0.30-1.80 0.50Body mass index in kg/m2 - mean (±sd) 32.6(8.7) 31.1(8.8) 1.02 0.97-1.07 0.45 1.08 1.01-1.16 0.02Inhaled medications at the time of presentation - n(%) 20(83) 165(89) 0.61 0.19-1.95 0.40History of chronic steroid use - n(%) 1(4) 21(11) 0.34 0.04-2.63 0.30Received respiratory support during hospitalization - n(%) 5(21) 23(12) 0.54 0.18-1.59 0.26Number of blood glucose measurements taken per day - mean (±sd) 1.7(1.9) 2.6(1.8) 0.66 0.47-0.93 0.02
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ResultsResultsLOS
Hospitalization ≤ 2 days
Hospitalization > 2 days Univariate analysis Adjusted analysis
Characteristic: n = 109 n= 100 OR 95% CI p-value OR 95% CI p-value
Blood glucose (100 ng/ml decrease in daily mean) 1.44 1.01-2.04 0.04 1.58 1.09-2.29 0.01
Age (years) at hospital admission - mean (±sd) 64.5(8.5) 65.2(8.1) 1.01 0.98-1.04 0.54 0.97 0.93-1.01 0.18
Diabetes Mellitus at hospital admission - n(%) 32(29) 31(31) 1.08 0.60-1.95 0.80 1.22 0.60-2.50 0.59
Received respiratory support during hospitalization - n(%) 22(18) 6(6) 3.96 0.53-10.23 0.005
Complications during hospitalization - n(%) 20(18) 4(4) 5.39 1.77-16.39 0.003
Male sex - n(%) 42(39) 38(38) 0.98 0.56-1.71 0.94
Corticosteroids given within 24 hours of hospitalization - n(%) 105(97) 95(95) 0.54 0.13-2.33 0.41
Current smoker - n(%) 37(34) 46(46) 1.66 0.95-2.90 0.08
Body mass index in kg/m2 - mean (±sd) 31.4(9.4) 31.1(8.2) 1.00 0.97-1.03 0.80
Inhaled medications at the time of presentation - n(%) 98(90) 87(87) 0.75 0.32-1.76 0.51
History of chronic steroid use - n(%) 12(11) 10(10 0.91 0.37-2.21 0.83
Number of blood glucose measurements taken per day - mean (±sd) 2.3(2.0) 2.7(1.6) 1.13 0.97-1.32 0.12
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ResultsResultsLOS
• Unadjusted, BG modeled continuously was not associated with LOS (OR: 1.25, 95% CI: 0.87-1.81, p-value: 0.22)
• Adjusting for age and DM, decreased BG was associated with a longer LOS (OR for 100 ng/ml decrease: 1.39, 95% CI 1.04-1.87, p-value: 0.03)
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ResultsResultsThirty day readmission
• Thirty six people were readmitted within 30 days of discharge from index hospitalization
• BG was not associated with 30 day readmission • Unadjusted OR: 1.34, 95% CI: 0.78-2.28, p-value
0.29• Adjusting for DM, age, and BMI: 1.34, 95% CL
0.75-2.41, p-value: 0.33
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ResultsResultsNinety day mortality
• Eight people died due to any cause within 90 days of index hospitalization
• BG was not associated with 90 day all cause mortality• Unadjusted OR: 2.68, 95% CI: 0.92-7.79, p-value
0.07• Adjusting for DM, age, and BMI: 1.93, 95% CL
0.55-6.75, p-value: 0.30
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ResultsResultsMediation analysis
• Tested how much of the association between in-hospital complications and length of stay could be attributed to BG.• Found that 4% of that association is due to BG (p =
0.07)
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DiscussionDiscussion
• Decreased BG has a marginal and weak association with in-hospital complications and longer LOS• BG may be reflective of overall health in this
population• No association with 30 days readmission or
90 day all-cause mortality• BG (as we measured it) probably of little
prognostic utility in AECOPD patients
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DiscussionDiscussion
• Different than the study by Baker et al.• May be due to difference in exposure and
outcome definition• Repeated their method on our data and found no
association
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DiscussionDiscussion
• Future studies• Employ continuous glucose monitoring to fully
understand the complexities of corticosteroid usage, the glycemic response and clinical outcomes in this group of people
• Study the association between metabolic syndrome and clinical outcomes and how much glycemic status contributes to that association
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DisclosureDisclosure
The authors do not have conflicts of interest to report.
This study was funded by a Marshfield Clinic Research Foundation resident research grant.