Sunday, August 18, 2013

Inappropriate Management of Hypertension and Diabetes in the Hospital



A great Viewpoint in JAMA Internal Medicine describes an important and common cause of over treatment and medication errors in hospitalized patients:   Intensifying treatment for chronic problems that are best managed in the outpatient setting.  The two most common culprits are hypertension and diabetes.

As our UCSF colleagues, Michael Steinman and Andrew Auerbach aptly note in this viewpoint, many patients, especially older patients, are admitted for acute problems like pneumonia.  They also have hypertension, diabetes, or other conditions that are unrelated to the reason for admission.

A well intentioned hospital physician may see the hospitalization as an opportunity to "tune up" the patient by intensifying treatment for these conditions.  But, this usually does more harm than good.  Unless these conditions are out of control, or their treatment is part of the treatment of the acute illness, the patient will be better served by a less is more approach, leaving management to the outpatient doctor.

There are two big problems with intensifying treatment for chronic conditions such as hypertension and diabetes in the hospital.

First, acute illness often causes transiently worse control of hypertension and diabetes.  Control will likely return to normal after the acute illness resolves.  But when treatment is intensified in the hospital, the patient goes home dangerously over treated.  In their viewpoint, Steinman and Auerbach give an example of a patient in whom intensification of blood pressure treatment in the hospital led to potentially dangerous low blood pressure after the patient went home.

Second, it is simply impossible to determine the ideal regimen for blood pressure and glucose control in the hospital.  It makes no sense to try to carefully titrate meds for these conditions in the hospital where the patient's activity and dietary regimen is completely different from their home regimen.  We may feel good by making all the numbers look good in the hospital but the numbers will be very different when the patient goes home.  Close titration of blood pressure and blood sugar in the hospital is usually futile.

Hospital physicians should think twice before trying to change established outpatient regimens for hypertension and diabetes in the hospital.  Changes should only be made in consultation with the outpatient physician.

by: Ken Covinsky

6 comments:

Bruce Scott said...

Yes.

In particular, hospitalists and inpatient resident ward teams seem to target particularly aggressive goals in elderly patients that would be more appropriate in younger patients but dangerous and inappropriate in our elders. I NEVER get called about them before these changes are made. Moderate Alzheimer's patients get put on insulin or new anti-hypertensives.

Either my eyes are getting worse or the Captchas are getting harder. Pretty soon they may as well say "Please prove you're under 40" instead of "Please prove you're not a robot".

ken covinsky said...

Bruce--thank you for your comments. I think you are on to something really important---the hospital as a contributor to overmedicalization and polypharmacy in the very frail and patients with dementia. It strikes me that frailty and dementia often have no impact on the care provided by inpatient teams.

Your comment makes me think of the important observation Joan Teno made about feeding tubes in patients with advanced dementia. 2/3 are inserted during acute care hospitalizations---not in the nursing home. This all illustrates the importance of leaving treatment decisions that do not need to be made acutely to the outpatient team that best knows the patient.

http://www.ncbi.nlm.nih.gov/pubmed/20145231

Moshe said...

Re: Feeding tubes in acute hospitalizations

As a resident in internal medicine, we deal with these issues all the time. Elderly patients are hospitalized with pneumonia, UTI, bacteremia, etc... Their level of consciousness is decreased and they are simply unable to eat on their own. Should we starve them for 3-5 days (presuming that they will recover) until they are discharged to the nursing home? Obviously, when they are stable they can eat normally (albeit with help), in acute illnesses they are unable to do so.

Please don't blame us for not starving our patients to death.

Eric Widera said...

Moshe,

Ken's referenced an article that looks at endoscopic or surgical insertion of a gastrostomy tube during a hospitalization. This is not nasogastric tube for a couple days while delirium is resolving. It's also not a question of starving someone vs feeding by the PEG, as careful hand feeding and comfort feeding should be the standard of care for these patients.

The sad state of affairs with these PEG or PEJ tubes is that it matters greatly on what hospital you get admitted to. In a study of NH residents admitted to the hospital the rate of feeding tube insertion varied 0 to 38.9 per 100 hospitalizations. Higher rates in for-profit hospitals that were large and had more ICU use in the last 6 months of life (JAMA. 2010;303(6):544-550).

Janice Reynolds said...

Returning to the subject of over treating of HTN and DM when the elderly are hospitalized. The point that acute illness causes changes in both of these is an important one to remember which is why unless they were a reason or contributing reason they shouldn't be addressed during the acute hospitalization. If someone's HCA1B comes back at 8 then get things started but don't get drastic. One case I remember a woman with fairly advanced Dementia had broken her hip and the family had elected to go with palliative care instead of surgery. She was only taking a little Ensure-not eating at all (and this was not new for her) and her blood sugars were being done QID. This upset her family and as a palliative care nurse I was able to get them dropped to BID (couldn't get them stopped entirely). The orthopedic surgeon was very upset as he had heard one of the intensivist lecture on keeping tight glycemic control in order to enhance healing. He didn't seem to "get" that our goal was to make this person as comfortable as possible and "healing" would not be likely at this point in this lady's life. So when tweaking un-acute problems maybe asking what our "goal" for this hospitalization is may be helpful.

kathy kastner said...

I learn so much from GeriPal and comments.. This is yet anther important piece for us non- healthcare professionals to know and accept, so we can make decisions borne of understanding of a larger picture rather than guilt or pressure (or knee jerk reaction). Many thanks for putting this into humane perspective. Although meant for healthcare professionals, I'll be linking to it on my made-for-real-people-blog BestEndings.com. Kathy Kastner