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

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

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

Afiliação

Pilla SJ; Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Meza KA; Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
Beach MC; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
Long JA; Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Gordon HS; University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
Bates JT; Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Washington DL; Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
Bokhour BG; Corporal Michael J. Cresenz VA Medical Center, Philadelphia, PA, USA.
Tuepker A; Division of General Internal Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
Saha S; Jesse Brown VA Medical Center, Chicago, IL, USA.
Maruthur NM; Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA.

Lancet Reg Health Am ; 28: 100641, 2023 Dec.

Article em En | MEDLINE | ID: mdl-38076413

ABSTRACT

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.