My Experience with Research - SHM Student and Resident Research Grant
Author: Brian Sangalang, Medical Student, University of California Riverside School of Medicine
Faculty Mentor: Dr. Scott Kubomoto, MD, Assistant Clinical Professor of Health Science, University of California Riverside
SHM Mentor: Dr. Anne Linker, MD, Assistant Professor of Medicine, Mount Sinai Hospital
When I was younger, my grandmother told me to always be curious because curiosity leads to new learning and discovery. This lesson has stayed at the forefront of my mind throughout college throughout all my classes but sitting through lectures was never enough and I was always looking for something more. This past summer, I had the opportunity to participate in clinical research and the ability to apply my knowledge to solve a real-world problem had me hooked.
Starting in 2023, the Centers for Medicare and Medicaid Services (CMS) is adding a new electronic clinical quality measure (eCQM) for inpatient hypoglycemia. Shockingly, over half of the incidents of hypoglycemia in hospitalized diabetic patients involved those with CKD and 18% of patients with end-stage renal disease (ESRD) had a hypoglycemic episode while hospitalized. Why is this so? Our aims were two-fold with the primary objective being the determination of risk factors associated with these hypoglycemic episodes and the second being the implementation of an intervention to decrease these incidences.
I spent the summer analyzing a database and looking at inpatient hypoglycemia episodes among those with diabetes mellitus (DM) and ESRD. What I found was that hypoglycemia episodes were typically occurring in the early morning, and the patients usually received a seemingly large dose of long-active insulin the night before. These patients were also subjectively on more aggressive insulin sliding scales which may have played a role in their hypoglycemia. The next question on our minds was which played a larger role in the development of hypoglycemia? Truthfully the answer to that is unclear which is the beauty of research. We decided to investigate whether the dose of long-acting insulin the night prior was the bigger culprit. Part of that decision was based on the fact that subsequent night-time doses of long-acting insulin were lowered suggesting that the physician involved suspected that it may have contributed to the hypoglycemic episode. This was just one of several potential risk factors we decided to investigate. Statistical studies are still being performed to complete our primary objective. In order to reach our secondary objective, we implemented a text notification into the electronic medical record (EMR) ordering screen for long-acting insulin alerting providers to be aware of their insulin dosing when dealing with patients with DM and ESRD and suggesting a less aggressive dose. This is a relatively minor intervention and data is currently being collected on its effectiveness.
The implications that this project has are limitless. I for one was flabbergasted after finding out that there were no clear insulin dosing guidelines for diabetic patients on hemodialysis. Not only do ESRD patients have a decreased ability to clear insulin, but dialysis removes some glucose in the plasma so why aren’t there more specific guidelines on how to tailor insulin dosing in this case? Diabetes mellitus is one of the largest risk factors for developing CKD and so it can be fairly common for hospitalists to have patients with both. This project can set the foundation for further studies looking into developing more uniformed guidelines for hospitalists to use. Our intervention implementation would also give us guidance on what the best way to cause clinical behavioral change would be so that the issues we noted are actively being addressed.
Long term goals of the project would be to uncover more specific risk factors behind inpatient hypoglycemia as there are likely factors involved that are not captured in our database such as meal times and dialysis times.
Reflecting back on this project and the process, the growth that I’ve experienced as a hopeful future academic hospitalist has been immense. I’ve gained more confidence in thinking about issues critically and I feel more confident with research design and implementation. I’m grateful for the opportunity to carry out this work and I’m excited to see this to the end. Come find me at Converge 2023 to hear the conclusion of this project and say hello!
Bloggers
