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Jordan Messler: Hi everyone. Thanks for joining the session entitled Return on Investment Financial, Benefits of Optimal Glycemic Management. I’m Jordan Messler, the Chief Medical Officer here at Glytec. Happy to be joined here today by LaTivia Carr, the Vice President and Chief Nursing Officer at Riverside Healthcare and Dr. Priya Vellanki, Associate Professor, Division of Endocrinology, Metabolism & Lipids at Emory University School of Medicine and we’re going to talk about the money. That’s what matters to a lot of the executives that you talk to when you’re trying to build your case. We don’t always like talking about it, but there is a return on investment around glycemia.

And the background is really revolving around our goals of optimal glycemic management. When we talk about optimal glycemic management, we’re discussing about preventing hypoglycemia related to insulin or oral diabetes medications, and preventing and treating hyperglycemia, managing hyperglycemia while patients are here in the hospital. And both these issues are common, costly and in many ways, preventable.

Hypoglycemia is common, almost 20% of patients stays, they have a blood sugar reading less than 70. Uh, in many ways, preventable, related to insulin or oral diabetes medications. And many patients that have severe hypoglycemia, up to 40%, will have a repeat hypoglycemia event. And we certainly know it’s costly. We’re going to talk some about the cost. Some studies have tied excess cost related to severe hypoglycemia up to $21,000 per episode.

Some of our sites that we work with one, uh, Advent Health, have demonstrated some of these costs, related to severe hypoglycemia. This was prior to implementing Glucommander to help them build their case for why optimal glycemic management was important.

They saw that over $10,000 were related to severe hypoglycemia when compared to normal glycemia, extremely high costs of not preventing severe hypoglycemia. Other studies have shown that a recurrent hypoglycemic event can be upwards of $33,000 in costs. One of our sites, Kaweah Delta, uh, looked at the impact of preventing severe hypoglycemia, treating hyperglycemia and saw a cost saving per severe hypoglycemic event of almost $3,000.

Now the impact of untreated hyperglycemia. Again, we know it’s common. Work from Dr. Umpierrez, one of our speakers at this conference, has shown that up to almost 40% of patients in the hospital have diabetes or hyperglycemia, stress hyperglycemia. We also know that hyperglycemia in hospitals is often not treated. Either delays in treatment or not treated correctly with standards of care. Sliding scale insulin remains very commonly the method to manage hyperglycemia in the hospital. And often cited by clinicians is this fear of hypoglycemia.

And then clearly untreated hyperglycemia has a patient safety impact. Numerous studies showing the impact and variety of disease conditions associated with significant morbidity and mortality.

And we’ve shown at Glytec with our eGMS system, with Glucommander, that we can improve blood sugars. We’ve shown tighter glycemic control in the ICU setting on IV insulin, getting patients in range 80 to 120. We’ve shown improved time to target five hours, medium time to target blood sugar for patients with DKA on IV insulin.

And we know we can safely manage hyperglycemia. BBI, Basal/Bolus insulin, managed with Glucommander SubQ, getting patients in range with no severe hypoglycemia in this particular study. We can manage hyperglycemia. We shouldn’t have this fear of hypoglycemia when we can do it safely, particularly with technology like our eGMS system.

So where are those cost savings realized? Well, we’re talking about optimal glycemic management. If we’re able to prevent severe hypoglycemia, treat hyperglycemia, get the outcomes we want, this will translate into areas of cost saving. We’re seeing the serious safety event reduction, a morbidity reduction, translating into a length of stay reduction, readmission rate reduction, and begin to see those cost savings.

Let’s look a little closer at the financial benefits of optimal glycemic management, preventing severe hypoglycemia, treating persistent hyperglycemia. So look at a couple of categories. This is the w begins to show the way that we manage this and present this to our sites at Glytec. You might find other ways that you’re beginning to share how you can get a return on investment by optimizing glycemic management.

Hypoglycemia. So we’ve shown that we can reduce severe hypoglycemia. Again, that Kaweah Delta study and one of the conservative models and saving, showing that about $3,000 per episode of severe hypoglycemia. And again, from the other data I showed, some instances that really may be up to 10, 20, or recurrent hypoglycemia, $30,000 in savings.

In addition, some sites might cite reductions in malpractice suits from prevental hypoglycemia. And that may be another domain that you add when you’re doing return on investments analyses. You’re going to hear more about bypass surgery, CABG, from Dr. Vellanki. Our work with Glucommander and her group showing that patients in tighter control on IV Glucommander undergoing bypass surgery, had a $3,654 reduction in cost compared to more conservative, uh, control of blood sugar. And she’ll go through the details of that. In addition, you’ll hear from LaTivia about length of stay reduction. So we’ve seen 0.26 length of stay reduction. Numerous other studies outside of Glytec that have shown length of stay reductions from reductions and hypoglycemia, treating hyperglycemia that could reach up to three days. Again, you’ll hear from LaTivia shortly talking about, her site’s journey, with Glucommander and length of stay reduction.

So if we, we dive in even a little deeper thinking through an example, 400 bed hospital, we’re going to focus first on the table on the right. So, an example of a 400 bed hospital might have 372 severe hypo events per year. We’ve seen places with a variety of range. This would be pre introducing a system like Glucommander, where we’ve shown reductions up to 99.8% in severe hypoglycemia on IV insulin. We’ve shown reductions in 50 to 75% on SubQ Glucommander. Uh, so for this example, we’ll put 75% in the model. That’ll bring you down to 279 avoided severe hypoglycemic events, per year. If we use that Kaweah Delta number of almost $3,000, we get $818,000 in savings from that reduction in severe hypoglycemia. So 279, fewer severe hypoglycemic events per year translating into dollars that we can present to our executives when we’re trying to make the case.

If we look at bypass surgery, an example of a 400 bed hospital, that’s doing, um, a large volume of bypass surgery. So in this instance, 782 bypasses per year. Some places, every single patient that winds up having bypass surgery, winds up on IV insulin, but let’s do a conservative around 75%, most studies cite around 80% wind up on IV insulin. So those 586 patients that are placed on IV Glucommander, and from the study you’ll hear about from Dr. Vellanki relating to $3,654 in savings, we’re seeing over $2 million in savings uh, in this example of a 400 bed hospital, uh, doing a large amount of bypass surgery.

And then for our third row, we talked about reductions in length of stay. So for a 400 bed hospital, we can expect, uh, over a thousand patients, will meet indications to require IV insulin while they’re in the ICU, uh, again from LaTivia, we’ll see a length of stay reduction of 0.26 days, that’s opening up 288 bed days in this instance. That’s improving throughput, opening up bed days for other critically ill patients, surgical patients. We put in our example of $550, there may be a larger number that you would use in your institution on the cost per bed for an ICU, and projected annual savings here, $158,400.

So, if we put all that together, we’ve got our three rows hypoglycemia, uh, prevention, reducing that by again, a conservative 75% bypass surgery where in this study again, you’ll hear that nobody had severe hypoglycemia, so we’re not using the same savings from the row above. And then opening up ICU bed days, translating to over 3 million dollars.

And we’ve seen this. Again, in particular, I talked about one site who did a, an extensive financial analysis. They went from really largely a sliding scale insulin only hospital, to using the full suite of Glucommander IV insulin, Basal/Bolus insulin on Glucommander SubQ, and they saw those things we’re talking about, optimal glycemic management. 71% reduction in hypoglycemic patients during their stay, a 33% reduction in hyperglycemic patients, and then translating into the cost savings, we’re talking about length of stay and fully for that one year, uh, over $9 million in annual savings.

So this was one way to think through return on investment, how we’re thinking about it here. There’s other areas you know where you can translate optimal glycemic management into financial outcomes. Let’s dig a little deeper into some of these, and I’m going to hand off to our Riverside Healthcare colleague, LaTivia Carr, who’ll talk about her work there at Riverside.

[00:09:23] LaTivia Carr:
Thank you, Dr. Messler. I am LaTivia Carr. I am the Vice President and Chief Nursing Officer here at Riverside Healthcare. We are a 300 bed acute care facility located here in Kankakee, Illinois. We are a level two trauma center. We are stroke, chest pain and heart failure certified. We are also a magnet designated facility. Um, We just achieved our third designation this year. So very excited about that. And we have a full scope of inpatient behavioral health services from geriatric to pediatric and adult.

So today we’re going to talk about how do clinical and financial outcomes differ between patients whose insulin titrations were managed using Glucommander software and the patients whose insulin titrations were managed using a standard paper protocol. We also want to focus on a certain patient population, namely the COPD, CHF, and diabetic ketoacidotic patients.

Some of the clinical outcomes that we have been able to boast here at Riverside, when we evaluate the impact of Glucommander on our length of stay on hypoglycemia and glucose control, We performed a retrospective quality improvement study and as you can see, we had some very favorable outcomes.

We used critical care units of the organization and we collected data over a 12 month period. Our patient population consisted of 382 patients who required glucose management with IV insulin and/or subcutaneous insulin. For Glucommander, the number of patients that we were able to capture, were 174 compared to patients who were not on the Glucommander protocol, so standard paper, or if I might add, the old school method of the sliding scale protocol with an N of 208. And if you take a look at the results, they are really remarkable. Patients who are on a standard sliding scale, had an average daily blood glucose that was higher than those patients that were managed using Glucommander both in the critical care unit and, look at that length of stay. The length of stay for our critical care unit patients who were managed under Glucommander were significantly less then those managed with the standard sliding scale. And why that’s impactful to us is that we know the impact length of stay and length of stay index on the overall quality of patient care delivery, as well as the financial impact to the organization.

Every point that we are able to shave off of that length of stay, generates about half a million dollars to the bottom line of the organization. And not to mention the complications that are greatly reduced when we reduce the length of stay for our patients. That are able to discharge them safely without risking them to um, extended stay in the hospital, which could lead to falls and other care issues. When we look at the point of care rate for patients with severe hypoglycemia, we also see a significant decrease of those patients managed by Glucommander versus those patients that were managed by the sliding scale.

This means that after treatment, these patients experience less hypoglycemia as a result of treatment, then those managed with the sliding scale. Why that’s important again, that speaks to the quality of care that we’re able to deliver to our patients and we prevent those highs and lows, those major drops in highs and lows in our patients that could further compromise their stay here.

And what I am happy to also boast is that um, if you take a look at that final box on the slide here, we had zero patients have a readmission to the ICU unit after treatment on the general unit who were managed with Glucommander. What that means is patients who were formally in the ICU on an insulin, drip and were managed down to being able to be controlled with Glucommander subcutaneously and transferred off of the unit, did not bounce back to the ICU or readmit to the ICU within 24 to 48 hours. On average, we saw adversely one to two patients a month who were readmitted to the ICU, utilizing that sliding scale. So again, when we look at the clinical outcomes and what that means for our patients, we are very happy with the outcomes that we’ve been able to generate for our patients, as well as the financial impact or gains that it’s been able to drive for us as an organization by improving the quality of care we provide for this patient demographic.

Again, I think I alluded to this a little bit, but we saw an 18% lower critical care unit length of stay. Again, the length of stay index was 1.12 days with Glucommander versus 1.37 days with the sliding scale protocol.

We saw 73% fewer patients who experienced hypoglycemia, which is a reduction in blood sugar less than 40, with patients who were managed by Glucommander versus those who were on the sliding scale protocol. And again, no critical care unit bounce backs for for, 12 months, which again, I think is pretty remarkable when you look at the whole of the demographics of patients that we were serving during this time and measuring and monitoring so, COPD, heart failure, et cetera.

And here is the big drum roll. Our length of stay cost savings estimate by implementing the Glucommander software and protocol for our patients. Not only did it drive significant improvements in our quality of care delivery for those patients, this is the direct impact with managing patients on Glucommander. 3,500 patients added $2.1 million back to the bottom line of the organization, when we saw an average of 0.25 reduction in length of stay, which I think is pretty significant to point out.

When we talk about the cost of managing hypoglycemia better, and the savings that it provides to the organization, here at Riverside, we were seeing an estimate of $545,000 in savings by managing those patients better. What we know about hypoglycemic incidents or hypoglycemic episodes is that both patients require more treatment. They require more monitoring, again, which increases the length of stay, utilization of resources, which adds to the cost of care. This is what we were able to save by managing those patients. Hypoglycemic episodes better here at Riverside, which I think is pretty remarkable.

So onto key takeaways. One of the things that we learned very quickly as we began to launch Glucommander here at Riverside, is that we needed to ensure that we had multimodal engagement of all of our teams. We needed the patient and their families to understand the new methodology that we were launching and how it would help manage their blood sugar, because this is different oftentimes than what they have experienced in the past with us, if they are a chronic diabetic, as well as it’s a different method from the sliding scale insulin protocol.

We also needed to ensure that our providers understood and were bought into utilizing the Glucommander tool to ensure that we were able to maximize its benefits to our patients. Our nursing teams, because this was a new workflow for them, so we needed to make sure that they were onboard, educated and understood their role. As well as our ancillary teams. We worked really hard with our dietary partners and with our dieticians to ensure that our trained delivery times and our calorie counting, carb counting, everything, worked together to ensure that our patients had the best outcomes as we utilized and optimized the tool.

The next step in the takeaways for us, were optimizing our workflows. So we had to spend a lot of time working with physicians and with frontline staff developing standardized order sets.

We wanted to reduce care variation that existed because we really didn’t have a standardized way of managing our diabetic patients on the inpatient side. We had to also help our providers understand the custom order algorithms and how that applied to what they were able to order for their patients who didn’t necessarily fall under the standardized order sets, but we still needed to manage them utilizing Glucommander.

Um, nurse-driven protocols. Again, having that frontline team provide feedback on what’s going to be the best way to both launch, and deliver and capture the information needed to ensure that we were impacting patients and staff positively came from our front line.

And then, hugely, our EMR integration. So being able to integrate this tool into our Epic system was key for us from an efficiency standpoint and a provider and nurse satisfaction standpoint. And it helped to streamline things and make things easier. As we went forward, there was a lot to learn, but work flow optimization was certainly key for us here at Riverside.

And then, as I shared much of the data with you throughout this presentation, data transparency is also very huge. So obviously, here at the executive level, we want to see, you know, what is this providing to the organization from an outcomes perspective and how do we measure that? So creating dashboards, and we know that data drives change so, where do we need to focus? Where do we need to shift? And what’s working well?

So having that data, being able to share the data, both at the executive level, as well as cascaded down to the frontline so that they can see how their work is impacting our patients and how it’s overall impacting our organization positively is key. And it helps to boost morale, and it also helps to drive change.

We, um, like to review our data in real time. So utilizing our unit dashboards for the frontline staff, weekly for the nurse managers, monthly for myself and for the directors of nursing, and then quarterly is what we carry forward to our executive team and to our boards.

And so in summary, we have seen a significant impact on the quality of care that we’ve been able to deliver to our patients from a very positive perspective. And we are excited about the next steps and further EMR integration for our Glucommander software here at Riverside. Thank you.

[00:20:47] Jordan Messler: Thanks so much, LaTivia. That was a great example of the work you’re doing there at Riverside. To hear another case study, I’m going to hand over to Dr. Vellanki. We’ll talk about her work with the GLUCO-CABG study and the financial savings that were shown there in patients with tight control.
[00:21:01] Priyathama Vellanki: Thank you, Jordan. So now I will be speaking about the GLUCO-CABG study.
I am an Associate Professor in the Division of Endocrinology at Emory University. I mainly work at our county hospital, Grady Memorial Hospital, where we see a lot of patients with diabetes. So it’s a very pertinent topic in the inpatient setting.

And so mainly what I want to talk to you about is one of the studies that we did and the cost analysis that we did. And this is really looking at patients who had coronary artery bypass grafting surgery, and see what glucose control, what range of glucose control, is ideal. And ideal, I use that, there’s many nuances to it, versus standard of care, which we call conservative control.

And, you know, just as a background, I think most of you in the group know that hyperglycemia is very common in the inpatient setting. People in the ICU and in the non ICU setting, there was a 70% prevalence of hyperglycemia in people who have diabetes and approximately 30% of people who don’t have diabetes also have hyperglycemia. And the reason we care is that hyperglycemia is associated with increased length of stay, complications, increased prevalence or incidence of wound infections.

You know, obviously control of hyperglycemia is important. The question is, you know, what are the glucose targets? What glucose targets should we aim for? Um, And in the past, there was a study in Belgium by Greet Van den Berghe who showed that intensive control, so glucoses in the 80s to 110, in the ICU actually decrease complications.

However subsequent studies in the ICU have not been able to replicate the results for various reasons. And most recently in 2009, when I say recent, it’s one of the bigger studies that we have that informs standard of care, um, The NICE-SUGAR study was performed. It was a multicenter study with over 6,000 patients that tested whether intensive control, so glucose goal of 81-108, versus conservative control, so glucose less than 180, changed mortality. And what they showed was that actually people who had intensive, glucose control, the glucose levels of approximately 180 milligrams per deciliter in the ICU, had higher mortality. So as seen by that blue line in the graph to your right. Compared to those with conventional glucose control. And the reason for this is hypoglycemia. When you control glucose intensively, you’ll risk hypoglycemia. So if there is hypoglycemia, there’s moderate hypoglycemia, that chances of mortality, that is 1.5 times people who do not have hypoglycemia. With severe hypoglycemia, that risk increases to 3 times.

So because of this paper, our guidelines have loosened up some of their glucose control to less than 180, or, you know, glucose between 100-180. And what we did was we looked at the GLUCO-CABG study. What people didn’t know was, is glucose less than 140 versus glucose greater than 1 40, 141-180, did that make a difference in complications, specifically in patients who received a coronary artery bypass grafting surgery? And as part of this study, we recruited people who had the CABG, and they were randomized to either intensive control, which included glucose range between a 100 to 140 milligrams per deciliter, compared to conventional control, which was a glucose target of 140 to 180 and in order to achieve these different targets, as you can see, Glucommander was used to achieve the target glucoses that we wanted. So, the people with conservative control or conventional control had an average glucose of 154, and the people with intensive control had an average glucose of 132. And this resulted in actually no differences in complications. So if you see on Graph A, there were no differences in overall complication, composite of complication rates with intensive versus conservative control. The intensive control had slightly less complications that trended towards significance as shown by the clear bar versus the black bar, which is a conservative control. What was really interesting though, is we divided up the people who had a history of diabetes and who did not. Graph B shows the people with diabetes, with the history of diabetes. Graph C shows people who develop hyperglycemia in the hospital, but did not have diabetes. And what we found was that in the people without diabetes, Graph C, intensive control resulted in much lower complications compared to conservative control.

So therefore, you know, in a group of patients, intensive control, 100 to 140, doing it safely without hypoglycemia is very important and we use Glucommander to achieve this. And the rate of hypoglycemia did not differ significantly between the groups.

The other thing, you know, being at a county hospital, such as Grady, cost as one of the main issues. And so what we did as a follow-up, a post hoc analysis to this study, was looking at resource utilization. What are the costs?

And we calculated how much resources people with intensive control and conventional control needed. And really, people with intensive control, interestingly needed less resources there. It was less cost. And we looked at costs versus charges because cost is what we actually pay. And people with intensive control, as shown in the blue graph, had less pharmacy costs, less radiology costs, less laboratory, less actually stay in the ICU, less cost in the ICU. And overall had median cost savings of $3,654 per patient. And in addition, as seen on the graph on the right, the median total hospital costs in the intensive control group, as shown in the blue, were lower, peri-operative complications were lower. It wasn’t statistically significant, but it was lower. And the amounts, the units of resources, was also lower.

And again, average ICU length of stay was lower. It was 20% lower complications, 37% lower length of stay and again, a cost savings of $3,654 per patient. Which shows that, you know, intensive control using um, Glucommander is cost saving and may benefit patients who’ve had surgery, especially the ones in the ICU. Thank you. Please let us know if you have any questions.

[00:27:44] Jordan Messler: I really want to thank our speakers, Dr. Vellanki from Emory University and LaTivia Carr from Riverside, for going through their work on showing the financial savings related to optimal glycemic management.

Thanks for joining us. Please enjoy the rest of the sessions at our Time to Target conference.

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