title: Diabetes and the Association of Postoperative Hyperglycemia With Clinical and Economic Outcomes in Cardiac Surgery.
abstract: OBJECTIVE
  The management of postoperative hyperglycemia is controversial and generally does not take into account pre-existing diabetes. We analyzed clinical and economic outcomes associated with postoperative hyperglycemia in cardiac surgery patients, stratifying by diabetes status.
  
  
  METHODS
  Multicenter cohort study in 4,316 cardiac surgery patients operated on in 2010. Glucose was measured at 6-h intervals for 48 h postoperatively. Outcomes included cost, hospital length of stay (LOS), cardiac and respiratory complications, major infections, and death. Associations between maximum glucose levels and outcomes were assessed with multivariable regression and recycled prediction analyses.
  
  
  RESULTS
  In patients without diabetes, increasing glucose levels were associated with a gradual worsening of outcomes. In these patients, hyperglycemia (≥180 mg/dL) was associated with an additional cost of $3,192 (95% CI 1,972 to 4,456), an additional hospital LOS of 0.8 days (0.4 to 1.3), an increase in infections of 1.6% (0.5 to 2.8), and an increase in respiratory complications of 2.6% (0.0 to 5.3). However, among patients with insulin-treated diabetes, optimal outcomes were associated with glucose levels considered to be hyperglycemic (180 to 240 mg/dL). This level of hyperglycemia was associated with cost reductions of $6,225 (-12,886 to -222), hospital LOS reductions of 1.6 days (-3.7 to 0.4), infection reductions of 4.1% (-9.1 to 0.0), and reductions in respiratory complication of 12.5% (-22.4 to -3.0). In patients with non-insulin-treated diabetes, outcomes did not differ significantly when hyperglycemia was present.
  
  
  CONCLUSIONS
  Glucose levels <180 mg/dL are associated with better outcomes in most patients, but worse outcomes in patients with diabetes with a history of prior insulin use. These findings support further investigation of a stratified approach to the management of patients with stress-induced postoperative hyperglycemia based on prior diabetes status.
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY giampaolo.greco@mountsinai.org.
authors.forename: Giampaolo
authors.initials: G
authors.lastname: Greco
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Bart S
authors.initials: BS
authors.lastname: Ferket
authors.affiliation: Department of Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY.
authors.forename: David A
authors.identifier: http://orcid.org/0000-0002-4205-4838
authors.initials: DA
authors.lastname: D'Alessandro
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Wei
authors.initials: W
authors.lastname: Shi
authors.affiliation: Department of Cardiothoracic Surgery, NIH Heart Center at Suburban Hospital, Bethesda, MD.
authors.forename: Keith A
authors.identifier: http://orcid.org/0000-0003-1372-7244
authors.initials: KA
authors.lastname: Horvath
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Alexander
authors.initials: A
authors.lastname: Rosen
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Stacey
authors.initials: S
authors.lastname: Welsh
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Emilia
authors.initials: E
authors.lastname: Bagiella
authors.affiliation: Department of Cardiothoracic Surgery, Emory University Hospital Midtown, Atlanta, GA.
authors.forename: Alexis E
authors.initials: AE
authors.lastname: Neill
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Deborah L
authors.initials: DL
authors.lastname: Williams
authors.affiliation: Department of Cardiothoracic Surgery, NIH Heart Center at Suburban Hospital, Bethesda, MD.
authors.forename: Ann
authors.initials: A
authors.lastname: Greenberg
authors.affiliation: Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC.
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Browndyke
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH.
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.affiliation: Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA.
authors.forename: Mary Lou
authors.initials: ML
authors.lastname: Mayer
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, VA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Keim-Malpass
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Lopa S
authors.initials: LS
authors.lastname: Gupta
authors.affiliation: University HealthSystem Consortium, Chicago, IL.
authors.forename: Samuel F
authors.initials: SF
authors.lastname: Hohmann
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Annetine C
authors.initials: AC
authors.lastname: Gelijns
authors.affiliation: Cardiovascular Division, Brigham and Women's Hospital, Boston, MA.
authors.forename: Patrick T
authors.initials: PT
authors.lastname: O'Gara
authors.affiliation: International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Moskowitz
mesh_terms: D000368:Aged; D001786:Blood Glucose / Q000032:analysis; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000191:economics; D002318:Cardiovascular Diseases / Q000150:complications / Q000601:surgery*; D003920:Diabetes Mellitus / Q000097:blood* / Q000188:drug therapy; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood* / Q000188:drug therapy / Q000191:economics / Q000209:etiology; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D011446:Prospective Studies; D013312:Stress, Physiological / Q000502:physiology; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose