Rationalization, Development, and Implementation of a Preoperative Diabetes Optimization Program Designed to Improve Perioperative Outcomes and Reduce Cost

Diabetes is an increasingly common medical condition affecting ∼29 million people (8 million of whom are undiagnosed), or 9% of the U.S. population. The estimated health expenditures to prevent and treat diabetes and associated direct and indirect complications totaled $245 billion in 2012, and this cost is on a trajectory to double by 2030 (1,2). An estimated 25% of patients with diabetes will require surgery (3). Twenty-eight percent of patients with diabetes are unaware that they have the disease (2). Furthermore, 5–10% of patients presenting for surgery are found to have previously unrecognized diabetes (4,5). This is particularly important because patients who are unaware of their diabetes have higher preoperative blood glucose levels (4) and a higher risk of perioperative mortality compared to patients who are aware of their diabetes (5). Diabetes is a well-known risk factor for postoperative infection, acute renal failure, ileus, and prolonged hospital stay (6–9). Poor preoperative glycemic control portends poor intraoperative glycemic control, which is an established risk factor for perioperative morbidity (10,11). Surgical patients with perioperative hyperglycemia (with and without underlying diabetes) have a greater risk for infection and related adverse outcomes after surgery compared to patients without hyperglycemia. Patients with diabetes are more prone to these surgical complications due to the microangiopathy (e.g., nephropathy and neuropathy) and macroangiopathy (e.g., atherosclerosis) intrinsic to the disease and also have mortality rates significantly greater than those of patients without diabetes (12–16). When patients with poorly controlled diabetes present for surgery, they impose a significant financial health resource burden, including prolonged ventilator dependence, longer hospital stay, and greater postoperative loss of productivity. As the prevalence of diabetes increases, optimal screening, management, and timing of elective surgery for patients with diabetes has become a matter of increasing …