Abstract
Purpose
To examine the proportion of diabetes-focused clinical encounters in primary care and endocrinology practices where the evaluation for hypoglycemia is documented; and when it is, identify clinicians’ stated actions in response to patient-reported events.
Methods
A total of 470 diabetes-focused encounters among 283 patients nonpregnant adults (≥18 years) with type 1 or type 2 diabetes mellitus in this retrospective cohort study. Participants were randomly identified in blocks of treatment strategy and care location (95 and 52 primary care encounters among hypoglycemia-prone medications (i.e. insulin, sulfonylurea) and others patients, respectively; 94 and 42 endocrinology encounters among hypo-treated and others, respectively). Documentation of hypoglycemia and subsequent management plan in the electronic health record were evaluated.
Results
Overall, 132 (46.6%) patients had documentation of hypoglycemia assessment, significantly more prevalent among hypo-treated patients seen in endocrinology than in primary care (72.3% vs. 47.4%; P = 0.001). Hypoglycemia was identified by patient in 38.2% of encounters. Odds of hypoglycemia assessment documentation was highest among the hypo-treated (OR 13.6; 95% CI 5.5−33.74, vs. others) and patients seen in endocrine clinic (OR 4.48; 95% CI 2.3−8.6, vs. primary care). After documentation of hypoglycemia, treatment was modified in 30% primary care and 46% endocrine clinic encounters; P = 0.31. Few patients were referred to diabetes self-management education and support (DSMES).
Conclusions
Continued efforts to improve hypoglycemia evaluation, documentation, and management are needed, particularly in primary care. This includes not only screening at-risk patients for hypoglycemia, but also modifying their treatment regimens and/or leveraging DSMES.
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References
R. Rodriguez-Gutierrez, K.J. Lipska, R.G. McCoy, N. Singh Ospina, H.H. Ting, V.M. Montori, Hypoglycemia as an indicator of good diabetes care. BMJ 352, i1084 (2016)
E. Ferrannini, S.J. Ramos, A. Salsali, W. Tang, J.F. List, Dapagliflozin monotherapy in type 2 diabetic patients with inadequate glycemic control by diet and exercise: a randomized, double-blind, placebo-controlled, phase 3 trial. Diabetes Care 33, 2217 (2010)
American Diabetes Association (ADA), 6. Glycemic targets: standards of medical care in diabetes-2019. Diabetes Care 42(Supplement 1), S61 (2019)
K. Khunti, M. Davies, A. Majeed, B.L. Thorsted, M.L. Wolden, S.K. Paul, Hypoglycemia and risk of cardiovascular disease and all-cause mortality in insulin-treated people with type 1 and type 2 diabetes: a cohort study. Diabetes Care 38, 316 (2015)
R.G. McCoy, K.J. Lipska, X. Yao, J.S. Ross, V.M. Montori, N.D. Shah, Intensive treatment and severe hypoglycemia among adults with type 2 diabetes. JAMA Intern. Med. 55905, 1 (2016)
E. Marrett, L. Radican, M.J. Davies, Q. Zhang, Assessment of severity and frequency of self-reported hypoglycemia on quality of life in patients with type 2 diabetes treated with oral antihyperglycemic agents: a survey study. BMC Res. Notes 4, 251 (2011)
R.A. Whitmer, A.J. Karter, K. Yaffe, C.P.J. Quesenberry, J.V. Selby, Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 301, 1565 (2009)
T. Anderbro, L. Gonder-Frederick, J. Bolinder, P. Lins, R. Wredling, E. Moberg, J. Lisspers, U. Johansson, Fear of hypoglycemia: relationship to hypoglycemic risk and psychological factors. Acta Diabetol. 52, 581 (2015)
R. Silbert, A. Salcido-Montenegro, R. Rodriguez-Gutierrez, A. Katabi, R.G. McCoy, Hypoglycemia among patients with type 2 diabetes: epidemiology, risk factors, and prevention strategies. Curr. Diab. Rep. 18, 53 (2018)
S.P. Rauh, F. Rutters, B.L. Thorsted, Self-reported hypoglycaemia in patients with type 2 diabetes treated with insulin in the Hoorn Diabetes Care System Cohort, the Netherlands: a prospective cohort study. BMJ Open 6, e012793 (2016)
J.N. Henderson, K.V. Allen, I.J. Dearyt, B.M. Frier, Hypoglycaemia in insulin-treated Type 2 diabetes: frequency, symptoms and impaired awareness. Diabet. Med. 21, 103 (2004)
E.R. Seaquist, J. Anderson, B. Childs, P. Cryer, S. Dagogo-Jack, L. Fish, S.R. Heller, H. Rodriguez, J. Rosenzweig, R. Vigersky, Hypoglycemia and diabetes: a report of a workgroup of the american diabetes association and the endocrine society. J. Clin. Endocrinol. Metab. 98, 1845 (2013)
A.J. Garber, M.J. Abrahamson, J.I. Barzilay, L. Blonde, Z.T. Bloomgarden, M.A. Bush, S. Dagogo-Jack, R.A. DeFronzo, D. Einhorn, V.A. Fonseca, J.R. Garber, W.T. Garvey, G. Grunberger, Y. Handelsman, I.H. B., P.S. Jellinger, J.B. McGill, J.I. Mechanick, P.D. Rosenblit, G.E. Umpierrez, Consensus Statement by the American Association of Clinical Endocrinologists and American College Of Endocrinology on the comprehensive type 2 diabetes management algorithm—2019 executive summary. Endocr. Pract. 25, 60 (2019)
VA/DoD clinical practice guideline for the management of type 2 diabetes mellitus in primary care [article online], 2017. https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoDDMCPGFinal508. Accessed 7 July 2019
NICE National Institute for Health and Care Excellence, type 2 diabetes in adults: management [article online], 2015. https://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management-pdf-1837338615493. Accessed 7 July 2019
M.J. Davies, D.A. D’Alessio, J. Fradkin, W.N. Kernan, C. Mathieu, G. Mingrone, P. Rossing, A. Tsapas, D.J. Wexler, J.B. Buse, Management of hyperglycemia in type 2 diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 61, 2461 (2018)
A. Cheung, T. Stukel, D. Alter, R. Glazier, V. Ling, X. Wang, B. Shah, Primary care physician volume and quality of diabetes care—a population-based cohort study. Ann. Intern. Med. 166, 240 (2017)
M.E. Charlson, P. Pompei, K.A. Ales, C.R. MacKenzie, A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J. Chronic Dis. 40, 373 (1987)
G. Leese, J. Wang, J. Broomhall, P. Kelly, A. Marsden, W. Morrison, B. Frier, A. Morris; DARTS/MEMO Collaboration, Frequency of severe hypoglycemia in patients with non-insulin-dependent diabetes mellitus treated with sulfonylureas or insulin. Endocr. Pract. 26, 1176 (2003)
A.P. Nunes, J. Yang, L. Radican, S.S. Engel, K. Kurtyka, K. Tunceli, S. Yu, K. Iglay, M.C. Doherty, D.D. Dore, Assessing occurrence of hypoglycemia and its severity from electronic health records of patients with type 2 diabetes mellitus. Diabetes Res. Clin. Pract. 121, 192 (2016)
M. Munshi, C. Slyne, A. Segal, N. Saul, C. Lyons, K. Weinger, Simplification of insulin regimen in older adults and risk of hypoglycemia. JAMA Intern. Med. 176, 1023 (2016)
R.G. McCoy, K.J. Lipska, J. Herrin, M.M. Jeffery, H.M. Krumholz, N.D. Shah, Hospital readmissions among commercially insured and Medicare advantage beneficiaries with diabetes and the impact of severe hypoglycemic and hyperglycemic events. J. Gen. Intern. Med. 32, 1097–1105 (2017)
M.L. Maciejewski, X. Mi, J. Sussman, M. Greiner, L.H. Curtis, J. Ng, S.C. Haffer, E.A. Kerr, Overtreatment and deintensification of diabetic therapy among Medicare beneficiaries. J. Gen. Intern. Med. 33, 34 (2018)
R. Kush, E. Helton, F. Rockhold, C. Hardison, Electronic health records, medical research, and the Tower of Babel. N. Engl. J. Med. 358, 1738 (2008)
J. Gill, A.J. Foy, Y. Ling, Quality of outpatient care for diabetes mellitus in a national electronic health record network. Am. J. Med. Qual. 21, 13 (2006)
UK Hypoglycaemia Study Group, Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia 50, 1140 (2007)
L. Donnelly, A. Morris, B. Frier, J. Ellis, P. Donnan, R. Durrant, M. Band, G. Reekie, G. Leese; DARTS/MEMO Collaboration., Frequency and predictors of hypoglycaemia in Type 1 and insulin-treated Type 2 diabetes: a population-based study. Diabet. Med. 22, 749 (2005)
M. Rendell, S. Saiprasad, A. Trepp-Carrasco, A. Drincic, The future of inpatient diabetes management: glucose as the sixth vital sign. Expert Rev. Endocrinol. Metab. 8, 195 (2013)
R. Rodríguez-Gutiérrez, N. Singh Ospina, R.G. McCoy, K.J. Lipska, N.D. Shah, V.M. Montori; Hypoglycemia as a Quality Measure in Diabetes Study Group, Inclusion of hypogycemia in clinical practice guidelines and performance measures in the care of patients with diabetes. JAMA Intern. Med. 176, 1714 (2016)
Acknowledgements
We thank Darrell Schroeder from the Mayo Clinic Department of Medicine Clinical Research Office and Division of Biostatistics, who was instrumental in identifying patients meeting inclusion criteria for the study and randomly selecting participants for each cohort.
Author contributions
R.R.-G., V.M.M. and R.G.M. analyzed the data, designed the research and wrote the manuscript. R.R.-G., A.S.-M., N.M.S.-O., S.M., N.I.-A., G.S.-B., S.U.T., K.J.L., performed the research and analyzed the data and reviewed the manuscript. R.R.-G. and R.G.M. are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
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The authors declare that they have no conflict of interest. R.G.M. is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number K23DK114497. S.M. receives support by the Arkansas Biosciences Institute, the major research component of the Arkansas Tobacco Settlement Proceeds Act of 2000. K.J.L. receives support from the National Institute on Aging and the American Federation of Aging Research through the Paul Beeson Career Development Award (K23AG048359) and from CMS to develop and maintain publicly reported quality measures. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the Mayo Clinic Institutional Review Board (reference number 10429) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Rodriguez-Gutierrez, R., Salcido-Montenegro, A., Singh-Ospina, N.M. et al. Documentation of hypoglycemia assessment among adults with diabetes during clinical encounters in primary care and endocrinology practices. Endocrine 67, 552–560 (2020). https://doi.org/10.1007/s12020-019-02147-w
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DOI: https://doi.org/10.1007/s12020-019-02147-w