title: Temporal trends and hospital variation in the management of severe hyperglycemia among patients with acute myocardial infarction in the United States.
abstract: BACKGROUND
  Elevated blood glucose is associated with higher mortality in patients with acute myocardial infarction (AMI). Although clinical guidelines recommend targeted glucose control in this group, clinical trials have yielded inconclusive results. Our objective was to understand how this lack of evidence impacts the management of severe hyperglycemia in routine practice.
  
  
  METHODS
  We examined insulin use among 4,297 AMI admissions with a mean hospitalization blood glucose of ≥200 mg/dL across 55 US hospitals from 2000 to 2008. Temporal trends and interhospital variation in 2 measures of insulin use during hospitalization-any (subcutaneous, intravenous [IV], short acting, long acting) and IV insulin-were examined using hierarchical Poisson regression models.
  
  
  RESULTS
  Of the 4,297 admissions, 2,618 (61%) received any insulin and 538 (13%) received IV insulin. After multivariable adjustment, a slight increase in insulin use was observed per admission year (relative risk [RR] 1.06, 95% CI 1.01-1.11). There was a modest (albeit nonsignificant) increase in IV insulin use seen before May 2004 (RR 1.18, 95% CI 0.96-1.47), with no significant change thereafter (RR 0.99, 95% CI 0.92-1.09). Marked variability in insulin use was observed across hospitals (median rate ratio 1.5 [any insulin] and 1.8 [IV insulin]), which did not change over time.
  
  
  CONCLUSIONS
  Insulin use among patients with AMI and severe hyperglycemia has remained low over the past decade, with substantial and persistent interhospital variation. These observations reflect marked clinical uncertainty with regard to glucose management in AMI, underscoring the imperative for a definitive clinical trial in this field.
authors.affiliation: University of Missouri-Kansas City School of Medicine, Kansas City, MO 64111, USA.
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Venkitachalam
authors.forename: Darren K
authors.initials: DK
authors.lastname: McGuire
authors.forename: Kensey
authors.initials: K
authors.lastname: Gosch
authors.forename: Kasia
authors.initials: K
authors.lastname: Lipska
authors.forename: Silvio E
authors.initials: SE
authors.lastname: Inzucchi
authors.forename: Marcus
authors.initials: M
authors.lastname: Lind
authors.forename: Abhinav
authors.initials: A
authors.lastname: Goyal
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Masoudi
authors.forename: Philip G
authors.initials: PG
authors.lastname: Jones
authors.forename: Mikhail
authors.initials: M
authors.lastname: Kosiborod
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000032:analysis; D015897:Comorbidity; D005260:Female; D006760:Hospitalization; D006761:Hospitals / Q000639:trends; D006801:Humans; D006943:Hyperglycemia / Q000150:complications / Q000188:drug therapy* / Q000209:etiology; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications*; D012737:Sex Factors; D014481:United States
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin