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Variability in Physician Care Practices for Glucose Treatment in Stroke Patients

Published online by Cambridge University Press:  02 December 2014

Leanne K. Casaubon ,
Alexandra Saltman ,
Valentina Peeva ,
Marguerite Ennis ,
Ngan Lam ,
Frank L. Silver  and
Moira K. Kapral
Leanne K. Casaubon*
Affiliation:
University Health Network University of Toronto, Toronto
Alexandra Saltman
Affiliation:
University Health Network
Valentina Peeva
Affiliation:
University Health Network
Marguerite Ennis
Affiliation:
Applied Statistician, Markham, Ontario, Canada
Ngan Lam
Affiliation:
University Health Network
Frank L. Silver
Affiliation:
University Health Network University of Toronto, Toronto
Moira K. Kapral
Affiliation:
University Health Network University of Toronto, Toronto
*
Dept. of Medicine, University of Toronto, Division of Neurology - Stroke Program, Toronto Western Hospital, West Wing 5-448, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada.
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Abstract

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Background:

Hyperglycemia is noted in up to 60% of stroke patients. Practice guidelines recommend glucose monitoring following stroke but provide few management recommendations. We examined physician care practices for glucose management in stroke patients.

Methods:

Emergency physicians, family physicians, general internists, intensive care specialists and neurologists in Ontario comprised the study population. A mailed, self-administered survey inquired about glucose management practices. Proportions of responses for survey questions were determined. Chi-square analysis was used for comparing physician groups.

Results:

Surveys were mailed to 2,280 physicians; 26.8% returned surveys. There were 278 respondents who reported providing stroke patient care. For physicians treating glucose in stroke patients, 16.6% targeted glucose 4.0-6.0 mmol/l, 52% targeted 6.1-8.0 mmol/l, 13.6% targeted 8.1-12.0 mmol/l, 0.8% targeted 12.1-15.0 mmol/l, and 7.5% were unsure. Comparing specialties, 32% of intensivists, 17.5% of neurologists, 13% of general internists, 14% of emergency physicians, and 0% of family physicians reported targeting 4.0-6.0 mmol/l (p=0.026). Overall, 44% reported aiming for target glucose within 12 hours and 77% within 24 hours from hospital presentation. Intensive care specialists treated glucose most aggressively, including 20% treating, with insulin infusion, patients with no diabetes and initial glucose 6.0-8.0 mmol/l. Emergency physicians were most conservative when treating glucose in stroke patients.

Conclusion:

There is variability in the aggressiveness of glucose management in stroke patients by different physician specialty groups, reflecting the lack of evidence available to guide hyperglycemia management in this setting. These results highlight an important gap in knowledge and recommendations for stroke patient care that must be addressed to ensure optimal patient outcomes.

Résumé:

RÉSUMÉ:Contexte:

Près de 60% des patients atteints d'un accident vasculaire cérébral (AVC) présentent une hyperglycémie. Les lignes directrices recommandent de surveiller le glucose après un AVC, mais elles fournissent peu de recommandations de traitement. Nous avons examiné les pratiques des médecins à ce sujet.

Méthodes:

La population de l'étude était constituée des urgentologues, des médecins de famille, des internistes, des intensivistes et des neurologues de l'Ontario. Nous avons distribué par la poste un questionnaire à compléter au sujet de leur attitude thérapeutique concernant le glucose. Nous présentons les réponses aux questions de l'enquête sous forme de proportions. Le test du chi-carré a été utilisé pour comparer les groupes de médecins.

Résultats:

Des questionnaires ont été postés à 2 280 médecins ; 26,8% ont retourné le questionnaire. Deux cent soixante-dix-huit répondants ont rapporté qu'ils traitaient des patients porteurs d'AVC. Parmi ceux qui traitaient le glucose chez les patients porteurs d'un AVC, 16,6% ciblaient un glucose entre 4,0 et 6,0 mmol/L, 52% ciblaient un glucose entre 6,1 et 8,0 mmol/L, 13,6% ciblaient un glucose entre 8,1 et 12,0 mmol/L, 0,8% ciblaient un glucose entre 12,1 et 15,0 mmol/L et 7,5% étaient indécis. Si nous comparons les réponses par spécialité, 32% des intensivistes, 17,5% des neurologues, 13% des internistes, 14% des urgentologues et 0% des médecins de famille ont rapporté une cible de 4,0 à 6,0 mmol/L (p = 0,026). Dans l'ensemble, 44% ont rapporté un chiffre cible pour le glucose dans les 12 heures et 77% dans les 24 heures de l'arrivée du patient à l'hôpital. Les intensivistes étaient ceux qui traitaient le glucose de la façon la plus agressive et 20% d'entre eux traitaient les patients non diabétiques avec un glucose initial de 6,0 à 8,0 mmol/L par une infusion d'insuline. Les urgentologues étaient les plus conservateurs dans le traitement du glucose chez les patients porteurs d'un AVC.

Conclusion:

Il existe une certaine variabilité dans l'attitude thérapeutique de différents groupes de spécialistes concernant le glucose chez les patients présentant un AVC. Cette constatation reflète l'absence de données pour guider le traitement de l'hyperglycémie dans ce contexte et souligne une lacune importante dans les connaissances et les recommandations thérapeutiques sur l'AVC qu'on devra combler pour optimiser le pronostic des patients atteints d'AVC

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 35 , Issue 5 , November 2008 , pp. 573 - 582
Copyright
Copyright © The Canadian Journal of Neurological 2008

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