Effects of Regular and Long-Acting Insulin on Cognition and Alzheimer's Disease Biomarkers: A Pilot Clinical Trial.

BACKGROUND: Long acting insulin detemir administered intranasally for three weeks enhanced memory for adults with Alzheimer's disease dementia (AD) or amnestic mild cognitive impairment (MCI). The investigation of longer-term administration is necessary to determine whether benefits persist, whether they are similar to benefits provided by regular insulin, and whether either form of insulin therapy affects AD biomarkers. OBJECTIVE: The present study aimed to determine whether four months of treatment with intranasal insulin detemir or regular insulin improves cognition, daily functioning, and AD biomarkers for adults with MCI or AD. METHODS: This randomized, double-blind, placebo-controlled trial included an intent-to-treat sample consisting of 36 adults diagnosed with MCI or mild to moderate AD. Participants received placebo (n = 12), 40 IU of insulin detemir (n = 12), or 40 IU of regular insulin (n = 12) daily for four months, administered with a nasal delivery device. A cognitive battery was administered at baseline and after two and four months of treatment. MRI was administered for all participants and lumbar puncture for a subset (n = 20) at baseline and four months. The primary outcome was change from baseline to four months on a memory composite (sum of Z scores for delayed list and story recall). Secondary outcomes included: global cognition (Alzheimer's Disease Assessment Scale-Cognition), daily functioning (Dementia Severity Rating Scale), MRI volume changes in AD-related regions of interest, and cerebrospinal fluid AD markers. RESULTS: The regular insulin treated group had better memory after two and four months compared with placebo (p < 0.03). No significant effects were observed for the detemir-assigned group compared with the placebo group, or for daily functioning for either group. Regular insulin treatment was associated with preserved volume on MRI. Regular insulin treatment was also associated with reduction in the tau-P181/Aß42 ratio. CONCLUSION: Future research is warranted to examine the mechanistic basis of treatment differences, and to further assess the efficacy and safety of intranasal insulin.

People, technology, and process meet the triple aim.

Banner Health is addressing the Triple Aim (quality care and satisfaction, improved health, and reduced cost) for Medicare beneficiaries by combining the people of one of the largest nonprofit health care systems in the United States (Banner Health) with innovative telehealth technology and leveraging high-reliability, standardized processes. The program, known as Banner iCare, builds on a highly successful tele-ICU program (some of the lowest mortality and length of stay results in the country) and expands the service to progressive care, medical-surgical, and emergency departments. These successes have led to the introduction of a home-based telehealth program with the strengths of the acute care programs. The top 5% high-cost patients with multiple chronic conditions receive coordinated intensive ambulatory care managed by an integrated team of health care professionals using cost-effective telehealth technology. The benefits expected from the proposed project include a reduction in overall costs while improving patient satisfaction through delivery of more personalized and interactive care.

The high cost of low-acuity ICU outliers.

Direct variable costs were determined on each hospital day for all patients with an intensive care unit (ICU) stay in four Phoenix-area hospital ICUs. Average daily direct variable cost in the four ICUs ranged from $1,436 to $1,759 and represented 69.4 percent and 45.7 percent of total hospital stay cost for medical and surgical patients, respectively. Daily ICU cost and length of stay (LOS) were higher in patients with higher ICU admission acuity of illness as measured by the APACHE risk prediction methodology; 16.2 percent of patients had an ICU stay in excess of six days, and these LOS outliers accounted for 56.7 percent of total ICU cost. While higher-acuity patients were more likely to be ICU LOS outliers, 11.1 percent of low-risk patients were outliers. The low-risk group included 69.4 percent of the ICU population and accounted for 47 percent of all LOS outliers. Low-risk LOS outliers accounted for 25.3 percent of ICU cost and incurred fivefold higher hospital stay costs and mortality rates. These data suggest that severity of illness is an important determinant of daily resource consumption and LOS, regardless of whether the patient arrives in the ICU with high acuity or develops complications that increase acuity. The finding that a substantial number of long-stay patients come into the ICU with low acuity and deteriorate after ICU admission is not widely recognized and represents an important opportunity to improve patient outcomes and lower costs. ICUs should consider adding low-risk LOS data to their quality and financial performance reports.

Physiologic monitoring alarm load on medical/surgical floors of a community hospital.

UNLABELLED: It has been known to the public that high frequency of false and/or unnecessary alarms from patient monitoring devices causes "alarm fatigue" in critical care. But little is known about the impact to care on the less acute patients located outside the critical care areas, such as the traditional medical/surgical (med/surg) floor. METHODS: As part of a larger population management study, we initiated continuous physiological monitoring to 79 beds of floor patients in a community hospital. In order to qualify the patient monitoring alarm load for subacute medical and surgical floor patients, we assessed alarm data from April 2009 to January 2010. A standard critical care monitoring system (Philips IntelliVue MP-5 and Telemetry) was installed and set to the default alarm limits. All waveform data available for the patient (typically ECG, RESP, PPG at 125hz 8 bit), all alarm conditions declared by the monitoring system, and 1 minute parameter trend data were saved to disk every 8 hours for all patients. A monitoring care protocol was created to determine whether the patient was monitored via the hardwired bedside or wirelessly via telemetry. Alarms were not announced on the care unit but instead notifications were the responsibility of remote telehealth center personnel. We retrospectively evaluated the frequency of alarms over specific physiologic thresholds (n= 4104 patients) and conducted adjudication of all alarms based on a smaller sampling (n=30 patients). RESULTS: For all patients, the average hours of monitoring per patient were 16.5 hours with a standard deviation (s) of 8.3 hours and a median of 22 hours. The average number of alarms (all severities) per patient was 69.7 (s =90.3, median =28) alarms. When this is adjusted to the duration of monitoring, the average per patient, per day rate was 95.6 (s =124.2, median =34.2) alarms. The adjudicated sample (n=30 patients) resulted in 34% of critical alarms (lethal arrhythmias, extreme high or low heart rate [HR], extreme desaturation, apnea) being true and 63% of the high priority alarms (high or low HR, high or low RR, Low SpO(2), pause, Missed Beat, Pair PVCs, Pacer Not Pace, Non Sustain VT, Irregular HR, Multiform) being true. Analysis of alarm history resulted in the ability to reduce the HR alarm load by more than 50% with a simple limit adjustment of high HR from 120 to 130 bpm and a 36% or 65% reduction in SpO(2) alarm load by reducing the SpO(2) limit from 90% to 85% or 80% respectively. CONCLUSION: 1) Standard critical care alarm limits appear be too sensitive for subacute care areas of the hospital. 2) For most patients these alarm limits do not create a significant alarm load; however, for a small number of patients they cause a significant alarm load. 3) Alarm loads can be controlled with alarm limit settings appropriate to the population. 4) Current technology for HR and SpO(2) appear suitable for continuous monitoring of this population.