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Stress hyperglycemia (SH) is a manifestation of altered glucose metabolism in acutely ill patients which worsens outcomes and may represent a risk factor for diabetes. Continuity of care can assess this risk, which depends on quality of hospital clinical documentation. We aimed to determine the incidence of SH and documentation tendencies in hospital discharge summaries and continuity notes. We retrospectively examined diagnoses during a 12-months period. A 3-months representative sample of discharge summaries and continuity clinic notes underwent manual abstraction. Over 12-months, 495 admissions had ≥ 2 blood glucose measurements ≥ 10 mmol/L (180 mg/dL), which provided a SH incidence of 3.3%. Considering other glucose states suggestive of SH, records showing ≥ 4 blood glucose measurements ≥ 7.8 mmol/L (140 mg/dL) totaled 521 admissions. The entire 3-months subset of 124 records lacked the diagnosis SH documentation in discharge summaries. Only two (1.6%) records documented SH in the narrative of hospital summaries. Documentation or assessment of SH was absent in all ambulatory continuity notes. Lack of documentation of SH contributes to lack of follow-up after discharge, representing a disruptor of optimal care. Activities focused on improving quality of hospital documentation need to be integral to the education and competency of providers within accountable health systems.

Background: Inhaled corticosteroids (ICS) produce local effects on upper airway dilators that could increase the risk of developing obstructive sleep apnea (OSA). Given that the particle size of ICS changes their distribution, the particle size of ICS may impact the risk of developing OSA. Objectives: In this large retrospective study, we explore the relationship of ICS use and OSA in patients with asthma. In addition, we seek to determine if this relationship is affected by the particle size of ICS. Methods: Using electronic health records, we established a cohort of 29,816 asthmatics aged 12 and older with a diagnosis of asthma documented by ICD-9 or ICD-10 codes between January 2011 and August 2016. We performed analyses of variance and multivariate logistic regression analysis to determine the effects ICS on the diagnosis of OSA with sub-analysis by particle size of ICS. Results: Uncontrolled asthmatics showed increased odds of receiving a diagnosis of OSA whether when looking at ACT scores (adjusted odds ratio (aOR) 1.60, 95% CI 1.32&ndash, 1.94) or PFT results (aOR 1.45, 95% CI 1.19&ndash, 1.77). Users of ICS also had increased odds of OSA independent of asthma control (aOR 1.58, 95% CI 1.47&ndash, 1.70). Notably, users of extra-fine particle ICS did not have significantly increased odds of having OSA compared to non-users of ICS (aOR 1.11, 95% CI 0.78&ndash, 1.58). Conclusions: Use of ICS appears to be an independent risk factor for OSA. Notably, extra-fine particle size ICS do not appear to be associated with an increased risk of OSA.

IntroductionInnovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations.Research design and methodsThe tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9–4.4 mmol/L (70–80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods.ResultsWhen active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, pConclusionEMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.

Diabetes (DM) prevalence continues rising at alarming rates. The disease is debilitating resulting in significant morbidity, mortality, and psychosocial challenges for nations across the globe. Models of care largely aim at treating and rehabilitating, while emphasis on wellness promotion, prevention, and early detection requires greater attention. Data capture through electronic medical records (EMRs) has become more prevalent. Reliable mechanisms to assess people at risk for DM and to intervene early are needed. In this study we developed and validated an EMR detection tool to identify under recognized cases of prediabetes (preDM). A series of decision support algorithms were deployed to query EMR data in an academic medical center to identify adults who met industry acceptable clinical criteria of glycohemoglobin (A1c) for preDM, but were not diagnosed within a defined diagnostic code range. Additional data included demographics and medications for DM or preDM. For verification, the collected data was reviewed for accuracy. Within a 22 weeks period, the algorithm screened among 37,997 adult patients discharged from inpatient or observation units, same day admission and emergency department. The screening tool searched for subjects ≥ 18 years whose primary care was provided within the organization, with A1c levels between 5.7 to 6.4%, not receiving pharmacological treatment for preDM, and lacking a discrete diagnosis of preDM. A total of 255 subjects were identified with these criteria and 209 cases (82%) confirmed for accuracy. The imprecision resulted from having one of the following: diagnosis code of preDM in their record in another format (37), diagnosis code for DM (7), or A1c ≥ 6.5% (2). Our first iteration of a preDM detection algorithm recognizes an important condition that precedes DM among people at risk of being unrecognized. The algorithm can be applied to all care areas; ambulatory and inpatient settings. This tool provides a mechanism beyond practice performance to accountably identify preDM. It represents an effective strategy to use EMR data for disease identification, with potential demonstrable outcomes for meaningful use of the EMR and for population management. Future refinement of this tool will revise and expand on diagnostic documentation codes to increase its accuracy. Our actionable strategy in progress includes a clinical decision support program for awareness and recommendations to providers and patients. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4-14 Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med 2010;363(6):501-4 Hersh W, Ehrenfeld, J.M. Clinical informatics. In: Skochelak SE, Hawkins, R.E., Lawson, L.E., Starr, S.R., Borkan, J.M., Gonzalo, J.D., editor AMA Education Consortium. Elsevier; 2017, p. 105-16

Social adversity can significantly influence the wellbeing of mothers and their children. Maternal health may be improved through strengthened support networks and better health literacy. Health improvement at the population level requires optimizing of the collaboration between statutory health services, civic organizations (e.g., churches, schools), as well as community groups and parents. Two key elements in improving community engagement are co-production and community control. This study evaluated a co-produced and community-led project, PACT (Parents and Communities Together), for mothers in a deprived south London borough. The project offered social support and health education. Intended effects were improvements in mental health, health literacy, and social support, assessed by standardized measures in a pre-post design. Sixty-one mothers consented to take part in the evaluation. Significant improvements were found in mental health measures, in health literacy, for those with low literacy at baseline, and in overall and some specific aspects of social support. Satisfaction with the project was high. We found that the project engaged local populations that access statutory health services relatively less. We conclude that community-organized and community-led interventions in collaboration with statutory health services can increase accessibility and can improve mothers&rsquo, mental health and other health-related outcomes.