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

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

The Lancet Regional Health. Americas (Dec 2023)

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

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

Affiliations

Scott J. Pilla: Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA; Corresponding author. 2024 E. Monument Street, Room 2-626, Baltimore, MD 21287, USA.
Kayla A. Meza: Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; University of Colorado Anschutz Medical Campus, Aurora, CO, USA
Mary Catherine Beach: Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
Judith A. Long: Corporal Michael J. Cresenz VA Medical Center, Philadelphia, PA, USA; Division of General Internal Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
Howard S. Gordon: Jesse Brown VA Medical Center, Chicago, IL, USA; Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA
Jeffrey T. Bates: Michael E. DeBakey VA Medical Center, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA
Donna L. Washington: 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; 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
Barbara G. Bokhour: Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA; Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
Anais Tuepker: Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA; Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
Somnath Saha: Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
Nisa M. Maruthur: Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA

Journal volume & issue: Vol. 28
p. 100641

Abstract

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Summary: 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).

Published in The Lancet Regional Health. Americas

ISSN: 2667-193X (Online)
Publisher: Elsevier
Country of publisher: United Kingdom
LCC subjects: Medicine: Public aspects of medicine
Website: https://www.thelancet.com/journals/lanam/home

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