Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study

Scott J Pilla; Kayla A Meza; Mary Catherine Beach; Judith A Long; Howard S Gordon; Jeffrey T Bates; Donna L Washington; Barbara G Bokhour; Anais Tuepker; Somnath Saha; Nisa M Maruthur

doi:10.1016/j.lana.2023.100641

Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study

Lancet Reg Health Am. 2023 Nov 24:28:100641. doi: 10.1016/j.lana.2023.100641. eCollection 2023 Dec.

Authors

Scott J Pilla^{1

2

3}, Kayla A Meza^{1

4}, Mary Catherine Beach^{1

5}, Judith A Long^{6

7}, Howard S Gordon^{8

9}, Jeffrey T Bates^{10

11}, Donna L Washington^{12

13}, Barbara G Bokhour^{14

15}, Anais Tuepker^{16

17}, Somnath Saha^{1

16}, Nisa M Maruthur^{1

2

18}

Affiliations

¹ Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
³ Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
⁴ University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
⁵ Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
⁶ Corporal Michael J. Cresenz VA Medical Center, Philadelphia, PA, USA.
⁷ Division of General Internal Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
⁸ Jesse Brown VA Medical Center, Chicago, IL, USA.
⁹ Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA.
¹⁰ Michael E. DeBakey VA Medical Center, Houston, TX, USA.
¹¹ Baylor College of Medicine, Houston, TX, USA.
¹² VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
¹³ Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
¹⁴ Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA.
¹⁵ Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
¹⁶ Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.
¹⁷ Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
¹⁸ Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.

Abstract

Background: Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits.

Methods: This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres in the US. Two investigators independently coded visit dialogue to classify discussions of hypoglycaemia history, anticipatory guidance, and adjustments to hypoglycaemia-causing medications according to diabetes guidelines.

Findings: There were 242 patients (one PCP visit per patient) and 49 PCPs. Two thirds of patients were treated with insulin and 40% with sulfonylureas. Hypoglycaemia history was discussed in 78/242 visits (32%). PCPs provided hypoglycaemia anticipatory guidance in 50 visits (21%) that focused on holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon were not discussed. Hypoglycaemia-causing medications were de-intensified or adjusted more often (p < 0.001) when the patient reported a history of hypoglycaemia (15/51 visits, 29%) than when the patient reported no hypoglycaemia or it was not discussed (6/191 visits, 3%). Haemoglobin A1c (HbA1c) was not associated with diabetes medication adjustment, and only 5/12 patients (42%) who reported hypoglycaemia with HbA1c <7.0% had medications de-intensified or adjusted.

Interpretation: PCPs discussed hypoglycaemia in one-third of visits for at-risk patients and provided limited hypoglycaemia anticipatory guidance. De-intensifying or adjusting hypoglycaemia-causing medications did not occur routinely after reported hypoglycaemia with HbA1c <7.0%. Routine hypoglycaemia assessment and provision of diabetes self-management education are needed to achieve guideline-concordant hypoglycaemia prevention.

Funding: U.S. Department of Veterans Affairs and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Keywords: Deprescriptions; Diabetes mellitus; Drug-related side effects and adverse reactions; Health education; Hypoglycemia.

Grants and funding

K23 DK128572/DK/NIDDK NIH HHS/United States