Previous: The Evidence for Low-Fat Diets Isn't Really There
Next: Obamacare Helped the Uninsured, but the Underinsured, Not So Much



View count:20,193
Last sync:2018-11-16 10:40
Like some kind of perpetual motion machine, it's hard to get physicians to change their behavior to do stuff. It's even harder to get them to change their behavior to stop doing stuff. This is Healthcare Triage News.

For those of you who want to read more, go here:

John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen - Graphics
It's hard to get physicians to change their behavior to do stuff. It's even harder to get them to change their behavior to stop doing stuff. This is Healthcare Triage News.

[intro music]

This week I wanna focus on a study from JAMA Internal Medicine entitled, "Effect of published scientific evidence on glycemic control in adult intensive care units."

So here's the deal. Some years ago, a study came out which said that there was a benefit to keeping people in the intensive care unit under tight glycemic control. In other words, to control the level of sugar in their blood pretty tightly. This meant that we had to monitor people's glucose levels closely and keep them between 80 and 110 milligrams per deciliter.

The rationale for this is based on lab data and observational studies that show that having tight control was associated with less hyperglycemia, fewer infections, and a greater chance of survival.

When a large randomized control trial was finally done, it showed that providing tight glycemic control to mostly surgical patients in the ICU led to 1 life saved for every 29 patients treated. And that's pretty awesome. So this became recommended practice.

Of course, this being medicine, soon we were providing tight glycemic control not only to critically ill surgical patients, but also nonsurgical patients. Cuz that's what we do.

Later, another study was done, called the Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation, or NICE-SUGAR, study. This was the biggest multinational RCT to examine tight glycemic control in a varied cohort of medical and surgical ICU patients.

It showed that tight glycemic control increased, not decreased, the risk of severe hypoglycemia, and increased 90-day mortality. Needless to say, these new data made everyone pause. They also led to some big changes in international guidelines modifying the recommendations for the management of blood glucose in critically ill patients.

The original study showing a benefit was published in 2001. The bigger study showing harm was published in 2009. This research, getting back to the paper we're talking about today, looked at how practice changed before and after the publication of the first study and the second study, from January 1st, 2001 through December 31st, 2012.

So before the publication of the first trial, about 17% of admissions to the ICU had tight glycemic control, 3% had hypoglycemia, and 40% had hyperglycemia. After publication of the first trial, for each quarter of the year, there were 1.7% more patients with tight glycemic control, 2.5% more with hypoglycemia, and 0.6% fewer with hyperglycemia.

This is consistent with what we'd expect a slow but steady adoption of tight glycemic control to do. However, after the publication of the second trial, there was no change in the percent of patients with tight glycemic control or hyperglycemia.

Here's a chart showing how tight glycemic control changed over time. There are a few things worth noting here. First, that it is hard to change physician behavior. Even with the first trial, it took years for people to adopt the use of tight glycemic control. But what's even more important to see, is that as hard as it is to get physicians to do something, it may be even harder to get them to stop doing something.

Tight glycemic control is more involved. It requires more activity, more intervention. It feels like you're caring for patients. Regular monitoring, on the other hand, especially after years of doing tight glycemic control, feels like ignoring patients and leaving them in danger. It's harder to do.

But we can't ignore this. It's why organizations like Choosing Wisely exist. Basically, they get together and point out things that doctors should stop doing in each specialty. We'll talk about it in a future episode.

We spend too much time talking about the things we should do, and too little focused on the things we should stop doing. Unfortunately, doing more often does harm. It also usually costs more money.

There's very little incentive for industry to encourage this type of research to try to get us to stop doing things. It's a public good. And we've gotta invest public money into it.

[outro music]