Acp presentation QI Diabetes - Mohan

1. Implementation of an Insulin Glargine
Titration Tool for Insulin Intensification for
Diabetic Patients in Primary Care
Mathini Mohanachandran, MD, R2

2. © 2018 Virginia Mason Health System

3. © 2018 Virginia Mason Health System
Background
• Insulin frequently used as 2nd or 3rd agent
• Barriers to starting/titrating insulin:
• High risk of hypoglycemia
• Injectable
• Variability in titration
• Confusion about instructions
• Concerns with rate of titration

4. © 2018 Virginia Mason Health System
Objectives
Development of a long acting insulin
algorithm
Impact of a standardized algorithm on
diabetes control in a medical system’s
primary care clinics

5. © 2018 Virginia Mason Health System
Treat To Target Trial
From: Rosenstock J, et al. A randomized, 52 week, treat-to-target trial
comparing insulin detemir with insulin glargine when administered as add-on to
glucose lowering drugs in insulin-naïve people with type 2 diabetes.
Diabetologia, 2008 Mar; 51(3):408-16.

6. © 2018 Virginia Mason Health System
Treat To Target Trial
From: Rosenstock J, et al. A randomized, 52 week, treat-to-target trial
comparing insulin detemir with insulin glargine when administered as add-on to
glucose lowering drugs in insulin-naïve people with type 2 diabetes.
Diabetologia, 2008 Mar; 51(3):408-16.

7. © 2018 Virginia Mason Health System
Treat To Target Trial
From: Rosenstock J, et al. A randomized, 52 week, treat-to-target trial
comparing insulin detemir with insulin glargine when administered as add-on to
glucose lowering drugs in insulin-naïve people with type 2 diabetes.
Diabetologia, 2008 Mar; 51(3):408-16.

8. © 2018 Virginia Mason Health System
Glargine Titration Algorithm

9. © 2018 Virginia Mason Health System
Glargine Titration Algorithm
• Standardized process tool
• Easy to use
• Increased efficacy/reduced duration of
titration
Long-acting
insulin initiated
at clinic visit
• Insulin at
prescribed dose
• Daily fasting
blood sugars
Care manager
call:
Titrate up insulin
dose per
algorithm
3 days

10. © 2018 Virginia Mason Health System
Improvement in A1C control

11. © 2018 Virginia Mason Health System
Conclusion
• Standardized algorithm utilizing
aggressive insulin titration through
nursing
• Safe and rapid titration
• Sustained improvement in glycemic
control

12. © 2018 Virginia Mason Health System
Thank You
• Grace Lee, MD
• Lynn A Benz, MPA, RN
• Nicholas Moy, MD
• Kim Pittenger, MD
• Glycemic Control Guidance Team
• Care Managers
• Patients