Primary care intervention may reduce hypoglycemia risk due to overtreatment in elderly with diabetes

A newly published quality improvement study shows how a simple intervention by health care providers reduced the number of older adult patients with type 2 diabetes at risk for hypoglycemia (low blood sugar) by almost 50% and led to de-escalation of diabetes medications that cause hypoglycemia in 20% of patients.

Twenty percent of Americans aged 65 and older have diabetes. This age group is particularly at risk for hypoglycemia because older people are often overtreated with insulin and other diabetes medications that can cause hypoglycemia. Severe hypoglycemia episodes in older adults can lead to adverse events such as falls, seizures, coma, and even death.

Severe hypoglycemia from insulin and certain oral type 2 diabetes medications is the second most common adverse drug event resulting in emergency room visits and hospitalizations in older people with diabetes.

“This study demonstrates that a low-cost clinical decision support tool, without the additional use of continuous glucose monitoring technology, can decrease the number of patients at high risk for hypoglycemia and reduce overtreatment with insulin and diabetes medications that cause hypoglycemia,” said study author Jeffrey B. Boord M.D., M.P.H., of Parkview Health System in Fort Wayne, Ind. Boord is the Chair of the Endocrine Society’s Hypoglycemia Prevention Initiative Steering Committee. “The patients in our study also reported significant reductions in the negative impact of hypoglycemia on their daily lives.”

The study included 94 patients at risk of treatment-related hypoglycemia at Pottstown Medical Specialists in Pottstown, Pa. Physicians were trained on how to use a clinical decision support (CDS) tool to facilitate shared decision making with patients and improve health outcomes.

During three clinic visits over 6 months, the clinicians used the tool to assess hypoglycemic risk, set individualized HbA1c (blood sugar level) goals, and reduce or discontinue the use of diabetes medications that can cause hypoglycemia.

The use of the clinical decision support tool and shared decision making reduced the at-risk population by 46% and led to the discontinuation of hypoglycemic medications in 20% of participants. Patients also completed a validated patient-reported outcome tool (TRIM-HYPO) to evaluate the impact of non-severe hypoglycemic events on their daily lives. The patients reported improvements in their daily functioning, emotional well-being, diabetes management, sleep disruption and work productivity related to reduction in non-severe hypoglycemic events.

“Because this intervention was so successful, we hope that our clinical decision support tool could be adopted for use in other primary care settings to lower the risk of hypoglycemia and improve the overall well-being of older adults with diabetes,” Boord said.

The HypoPrevent study was part of a larger, multi-year joint effort by the Endocrine Society and Avalere Health, known as the Hypoglycemia Prevention Initiative, to determine best practices in primary care to reduce the impact of hypoglycemia on older (65+) people with type 2 diabetes who use medications that cause hypoglycemia and have a recent A1c <7%, both of which put them at increased risk of hypoglycemia.

In conjunction with HypoPrevent, the Society formed a technical expert panel to develop quality measures—tools that help us measure or quantify healthcare processes, outcomes, patient perceptions and organizational structure—to reduce the risk of hypoglycemia in the outpatient setting. These performance measures are designed to help providers identify opportunities to improve patient care.

For details about the initiative including an implementation guide for how to use the clinical decision tool and resources on the key role of the diabetes educator, visit: endocrine.org/hypoglycemia-prevention-initiative.

The other authors of this study are Deborah A. Koehn of VCU Stony Point Women's Health in Richmond, Va.; Kathleen Marie Dungan of The Ohio State University in Columbus, Ohio; Amisha Wallia of Northwestern University Feinberg School of Medicine in Chicago, Ill.; Deborah Otcasek Lucas of Avalere Health and BridgingCare LLC in Washington, D.C.; Robert W. Lash and Mila N. Becker of the Endocrine Society in Washington, D.C.; and Lawrence D. Dardick of David Geffen School of Medicine at UCLA in Los Angeles, Calif.

The study was funded by Abbott Laboratories, Eli Lilly and Company, Merck, Novo Nordisk and Sanofi.

The study, “Reducing Hypoglycemia From Overtreatment of Type 2 Diabetes in Older Adults: The HypoPrevent Study,” was published in the Journal of the American Geriatrics Society.

References: Deborah A. Koehn, Kathleen Marie Dungan, Amisha Wallia, Deborah Otcasek Lucas, Robert W. Lash, Mila N. Becker, Lawrence D. Dardick, Jeffrey B. Boord, https://doi.org/10.1111/jgs.18566