University Medical Center Groningen Groningen, the Netherlands
Correspondence to: Jan G. Zijlstra, PhD, University Medical Center Groningen, Intensive and Respiratory Care, PO 30.001, Groningen 9700 RB, the Netherlands; e-mail: firstname.lastname@example.org
We congratulate Krinsley and Jones1–2 for their impressive improvement in patient survival, which was attributed to tight glucose regulation. Surprisingly, the intensification of therapy led to decreased costs, mainly due to shorter ICU and hospital stays. Fortunately, this finding has already been confirmed.3
However, they found1–2 a greater improvement in mortality than did van den Berghe et al4 in a key study. Moreover, in patients who were more comparable with the patients studied by Krinsley,1and Krinsley and Jones,2 they found no significant improvement in mortality in the intention-to-treat analysis, although a tighter upper limit of 110 mg/dL was used instead of 140 mg/dL.5
We wonder whether other factors might have influenced the findings. In a before-and-after study, subtle changes in policy or patient characteristics can easily influence outcome without apparent changes in APACHE (acute physiology and chronic health evaluation) II score or diagnostic groups. The obviously very comprehensive database should allow further analyses. It might be worthwhile to check for factors known to influence patient outcome. We would suggest checking the following: medical staff availability; nursing staff availability; nurse/patient ratio; bed occupancy ratio; rate of referred patients; availability of daily rounds; hospital admission and discharge protocols; the introduction of ventilatory protocols; and the introduction of early goal-directed therapy. This might moderate the effect of glucose regulation, putting it more in line with the results of van den Berghe et al.4 Otherwise, the effect on mortality of a single measure seems incredibly high.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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