Assessment and Prevention of Hypoglycaemia in Primary Care Among U.S. Veterans: A Mixed Methods Study

Authors

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

Publication Date

12-1-2023

Journal

The Lancet Regional Health – Americas

DOI

10.1016/j.lana.2023.100641

PMID

38076413

PMCID

PMC10701452

PubMedCentral® Posted Date

11-24-2023

PubMedCentral® Full Text Version

Post-Print

Published Open-Access

yes

Keywords

Diabetes mellitus, Hypoglycemia, Drug-related side effects and adverse reactions, Deprescriptions, Health education

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

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

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

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