Hypoglycemia Communication in Primary Care Visits for Patients with Diabetes

Abstract

Background

Hypoglycemia is a common and serious adverse effect of diabetes treatment, especially for patients using insulin or insulin secretagogues. Guidelines recommend that these patients be assessed for interval hypoglycemic events at each clinical encounter and be provided anticipatory guidance for hypoglycemia prevention.

Objective

To determine the frequency and content of hypoglycemia communication in primary care visits.

Design

Qualitative study

Participants

We examined 83 primary care visits from one urban health practice representing 8 clinicians and 33 patients using insulin or insulin secretagogues.

Approach

Using a directed content analysis approach, we analyzed audio-recorded primary care visits collected as part of the Achieving Blood Pressure Control Together study, a randomized trial of behavioral interventions for hypertension. The coding framework included communication about interval hypoglycemia, defined as discussion of hypoglycemic events or symptoms; the components of hypoglycemia anticipatory guidance in diabetes guidelines; and hypoglycemia unawareness. Hypoglycemia documentation in visit notes was compared to visit transcripts.

Key Results

Communication about interval hypoglycemia occurred in 24% of visits, and hypoglycemic events were reported in 16%. Despite patients voicing fear of hypoglycemia, clinicians rarely assessed hypoglycemia frequency, severity, or its impact on quality of life. Hypoglycemia anticipatory guidance was provided in 21% of visits which focused on diet and behavior change; clinicians rarely counseled on hypoglycemia treatment or avoidance of driving. Limited discussions of hypoglycemia unawareness occurred in 8% of visits. Documentation in visit notes had low sensitivity but high specificity for ascertaining interval hypoglycemia communication or hypoglycemic events, compared to visit transcripts.

Conclusions

In this high hypoglycemia risk population, communication about interval hypoglycemia and counseling for hypoglycemia prevention occurred in a minority of visits. There is a need to support clinicians to more regularly assess their patients’ hypoglycemia burden and enhance counseling practices in order to optimize hypoglycemia prevention in primary care.

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References

  1. 1.

    Lipska KJ, Yao X, Herrin J, McCoy RG, Ross JS, Steinman MA, et al. Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006-2013. Diabetes Care. 2017;40(4):468-75. https://doi.org/10.2337/dc16-0985.

    Article  PubMed  Google Scholar 

  2. 2.

    9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020;43(Supplement 1):S98-S110. https://doi.org/10.2337/dc20-S009.

  3. 3.

    Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care. 2013;36(5):1384-95. https://doi.org/10.2337/dc12-2480.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-12. https://doi.org/10.1056/NEJMsa1103053.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Lipska KJ, Ross JS, Wang Y, Inzucchi SE, Minges K, Karter AJ, et al. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med. 2014;174(7):1116-24. https://doi.org/10.1001/jamainternmed.2014.1824.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, et al. Severe hypoglycemia and risks of vascular events and death. N Engl J Med. 2010;363(15):1410-8. https://doi.org/10.1056/NEJMoa1003795.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Signorovitch JE, Macaulay D, Diener M, Yan Y, Wu EQ, Gruenberger JB, et al. Hypoglycaemia and accident risk in people with type 2 diabetes mellitus treated with non-insulin antidiabetes drugs. Diabetes Obes Metab. 2013;15(4):335-41. https://doi.org/10.1111/dom.12031.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP, Jr., Selby JV. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA. 2009;301(15):1565-72. https://doi.org/10.1001/jama.2009.460.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Bonds DE, Zaccaro DJ, Karter AJ, Selby JV, Saad M, Goff DC, Jr. Ethnic and racial differences in diabetes care: The Insulin Resistance Atherosclerosis Study. Diabetes Care. 2003;26(4):1040-6.

    Article  Google Scholar 

  10. 10.

    McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA. Increased mortality of patients with diabetes reporting severe hypoglycemia. Diabetes Care. 2012;35(9):1897-901. https://doi.org/10.2337/dc11-2054.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Karter AJ, Moffet HH, Liu JY, Lipska KJ. Surveillance of Hypoglycemia-Limitations of Emergency Department and Hospital Utilization Data. JAMA Intern Med. 2018;178(7):987-8. https://doi.org/10.1001/jamainternmed.2018.1014.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Misra-Hebert AD, Pantalone KM, Ji X, Milinovich A, Dey T, Chagin KM, et al. Patient Characteristics Associated With Severe Hypoglycemia in a Type 2 Diabetes Cohort in a Large, Integrated Health Care System From 2006 to 2015. Diabetes Care. 2018;41(6):1164-71. https://doi.org/10.2337/dc17-1834.

    Article  PubMed  Google Scholar 

  13. 13.

    Bloomfield HE, Greer N, Newman D, MacDonald R, Carlyle M, Fitzgerald P, et al. Predictors and Consequences of Severe Hypoglycemia in Adults with Diabetes - A Systematic Review of the Evidence. Washington, DC; 2012.

  14. 14.

    Pilla SJ, Segal JB, Maruthur NM. Primary Care Provides the Majority of Outpatient Care for Patients with Diabetes in the US: NAMCS 2009-2015. J Gen Intern Med. 2019;34(7):1089-91. https://doi.org/10.1007/s11606-019-04843-9.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Conlin PR, Colburn J, Aron D, Pries RM, Tschanz MP, Pogach L. Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus. Ann Intern Med. 2017;167(9):655-63. https://doi.org/10.7326/M17-1362.

    Article  PubMed  Google Scholar 

  16. 16.

    LeRoith D, Biessels GJ, Braithwaite SS, Casanueva FF, Draznin B, Halter JB, et al. Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab. 2019. https://doi.org/10.1210/jc.2019-00198.

  17. 17.

    4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020;43(Supplement 1):S37-S47. https://doi.org/10.2337/dc20-S004.

  18. 18.

    6. Glycemic Targets: Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020;43(Supplement 1):S66-S76. https://doi.org/10.2337/dc20-S006.

  19. 19.

    Bundesmann R, Kaplowitz SA. Provider communication and patient participation in diabetes self-care. Patient Educ Couns. 2011;85(2):143-7. https://doi.org/10.1016/j.pec.2010.09.025.

    Article  PubMed  Google Scholar 

  20. 20.

    Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17(4):243-52.

    Article  Google Scholar 

  21. 21.

    Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90. https://doi.org/10.1001/archinte.163.1.83.

    Article  PubMed  Google Scholar 

  22. 22.

    Heisler M, Cole I, Weir D, Kerr EA, Hayward RA. Does physician communication influence older patients’ diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS). J Gerontol A Biol Sci Med Sci. 2007;62(12):1435-42.

    Article  Google Scholar 

  23. 23.

    Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med. 2003;18(8):624-33. https://doi.org/10.1046/j.1525-1497.2003.31968.x.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    White RO, Osborn CY, Gebretsadik T, Kripalani S, Rothman RL. Health literacy, physician trust, and diabetes-related self-care activities in Hispanics with limited resources. J Health Care Poor Underserved. 2013;24(4):1756-68. https://doi.org/10.1353/hpu.2013.0177.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    White RO, Eden S, Wallston KA, Kripalani S, Barto S, Shintani A, et al. Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting. Patient Educ Couns. 2015;98(2):144-9. https://doi.org/10.1016/j.pec.2014.10.019.

    Article  PubMed  Google Scholar 

  26. 26.

    Boulware LE, Ephraim PL, Hill-Briggs F, Roter DL, Bone LR, Wolff JL, et al. Hypertension Self-management in Socially Disadvantaged African Americans: the Achieving Blood Pressure Control Together (ACT) Randomized Comparative Effectiveness Trial. J Gen Intern Med. 2020;35(1):142-52. https://doi.org/10.1007/s11606-019-05396-7.

    Article  PubMed  Google Scholar 

  27. 27.

    Ephraim PL, Hill-Briggs F, Roter DL, Bone LR, Wolff JL, Lewis-Boyer L, et al. Improving urban African Americans’ blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial. Contemp Clin Trials. 2014;38(2):370-82. https://doi.org/10.1016/j.cct.2014.06.009.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Ameling JM, Ephraim PL, Bone LR, Levine DM, Roter DL, Wolff JL, et al. Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans. Fam Community Health. 2014;37(2):119-33. https://doi.org/10.1097/FCH.0000000000000020.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Deary IJ, Hepburn DA, MacLeod KM, Frier BM. Partitioning the symptoms of hypoglycaemia using multi-sample confirmatory factor analysis. Diabetologia. 1993;36(8):771-7.

    CAS  Article  Google Scholar 

  30. 30.

    Crabtree BF, Miller WL. Doing qualitative research: Sage Publications; 1992.

  31. 31.

    Seed P. DIAGT: Stata module to report summary statistics for diagnostic tests compared to true disease status. 2010.

  32. 32.

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74.

    CAS  Article  Google Scholar 

  33. 33.

    McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb). 2012;22(3):276-82.

    Article  Google Scholar 

  34. 34.

    Ginde AA, Blanc PG, Lieberman RM, Camargo CA, Jr. Validation of ICD-9-CM coding algorithm for improved identification of hypoglycemia visits. BMC Endocr Disord. 2008;8:4. https://doi.org/10.1186/1472-6823-8-4.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Kruse RL, Olsberg JE, Oliver DP, Shigaki CL, Vetter-Smith MJ, LeMaster JW. Patient-provider communication about diabetes self-care activities. Fam Med. 2013;45(5):319-22.

    PubMed  Google Scholar 

  36. 36.

    Rodriguez-Gutierrez R, Salcido-Montenegro A, Singh-Ospina NM, Maraka S, Iniguez-Ariza N, Spencer-Bonilla G, et al. Documentation of hypoglycemia assessment among adults with diabetes during clinical encounters in primary care and endocrinology practices. Endocrine. 2019. https://doi.org/10.1007/s12020-019-02147-w.

  37. 37.

    Parchman ML, Romero RL, Pugh JA. Encounters by patients with type 2 diabetes--complex and demanding: an observational study. Ann Fam Med. 2006;4(1):40-5. https://doi.org/10.1370/afm.422.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Harris MI, Cowie CC, Howie LJ. Self-monitoring of blood glucose by adults with diabetes in the United States population. Diabetes Care. 1993;16(8):1116-23. https://doi.org/10.2337/diacare.16.8.1116.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Johnson PJ, Ghildayal N, Rockwood T, Everson-Rose SA. Differences in diabetes self-care activities by race/ethnicity and insulin use. Diabetes Educ. 2014;40(6):767-77. https://doi.org/10.1177/0145721714552501.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Vincze G, Barner JC, Lopez D. Factors associated with adherence to self-monitoring of blood glucose among persons with diabetes. Diabetes Educ. 2004;30(1):112-25. https://doi.org/10.1177/014572170403000119

    Article  PubMed  Google Scholar 

  41. 41.

    Martyn-Nemeth P, Schwarz Farabi S, Mihailescu D, Nemeth J, Quinn L. Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention - a review. J Diabetes Complications. 2016;30(1):167-77. https://doi.org/10.1016/j.jdiacomp.2015.09.003

    Article  PubMed  Google Scholar 

  42. 42.

    Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L. A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education. Patient Educ Couns. 2007;68(1):10-5. https://doi.org/10.1016/j.pec.2007.05.003.

    Article  PubMed  Google Scholar 

  43. 43.

    Fidler C, Elmelund Christensen T, Gillard S. Hypoglycemia: an overview of fear of hypoglycemia, quality-of-life, and impact on costs. J Med Econ. 2011;14(5):646-55. https://doi.org/10.3111/13696998.2011.610852.

    Article  PubMed  Google Scholar 

  44. 44.

    Zulman DM, Kerr EA, Hofer TP, Heisler M, Zikmund-Fisher BJ. Patient-provider concordance in the prioritization of health conditions among hypertensive diabetes patients. J Gen Intern Med. 2010;25(5):408-14. https://doi.org/10.1007/s11606-009-1232-1.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Peek ME, Quinn MT, Gorawara-Bhat R, Odoms-Young A, Wilson SC, Chin MH. How is shared decision-making defined among African-Americans with diabetes? Patient Educ Couns. 2008;72(3):450-8. https://doi.org/10.1016/j.pec.2008.05.018.

    Article  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Grant RW, Adams AS, Bayliss EA, Heisler M. Establishing visit priorities for complex patients: A summary of the literature and conceptual model to guide innovative interventions. Healthc (Amst). 2013;1(3-4):117-22. https://doi.org/10.1016/j.hjdsi.2013.07.008.

    Article  Google Scholar 

  47. 47.

    Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ. 2000;320(7244):1246-50. https://doi.org/10.1136/bmj.320.7244.1246.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Schoenborn NL, Crossnohere NL, Bridges JFP, Pollack CE, Pilla SJ, Boyd CM. Patient Perceptions of Diabetes Guideline Frameworks for Individualizing Glycemic Targets. JAMA Intern Med. 2019. https://doi.org/10.1001/jamainternmed.2019.3806.

  49. 49.

    Lawton J, Rankin D, Elliott J, Heller SR, Rogers HA, De Zoysa N, et al. Experiences, views, and support needs of family members of people with hypoglycemia unawareness: interview study. Diabetes Care. 2014;37(1):109-15. https://doi.org/10.2337/dc13-1154.

    Article  PubMed  Google Scholar 

  50. 50.

    Lucidi P, Porcellati F, Bolli GB, Fanelli CG. Prevention and Management of Severe Hypoglycemia and Hypoglycemia Unawareness: Incorporating Sensor Technology. Curr Diab Rep. 2018;18(10):83. https://doi.org/10.1007/s11892-018-1065-6.

    Article  PubMed  Google Scholar 

  51. 51.

    Cox DJ, Gonder-Frederick L, Ritterband L, Patel K, Schächinger H, Fehm-Wolfsdorf G, et al. Blood Glucose Awareness Training: What Is It, Where Is It, and Where Is It Going? 2006;19(1):43-9. https://doi.org/10.2337/diaspect.19.1.43 %J Diabetes Spectrum.

  52. 52.

    Rondags SM, de Wit M, van Tulder MW, Diamant M, Snoek FJ. HypoAware-a brief and partly web-based psycho-educational group intervention for adults with type 1 and insulin-treated type 2 diabetes and problematic hypoglycaemia: design of a cost-effectiveness randomised controlled trial. BMC Endocr Disord. 2015;15:43. https://doi.org/10.1186/s12902-015-0035-0.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Skovlund SE, Lichtenberg TH, Hessler D, Ejskjaer N. Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and a Case Study. Curr Diab Rep. 2019;19(9):84. https://doi.org/10.1007/s11892-019-1190-x.

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Jin Y, Li F, Vimalananda VG, Yu H. Automatic Detection of Hypoglycemic Events From the Electronic Health Record Notes of Diabetes Patients: Empirical Study. JMIR Med Inform. 2019;7(4):e14340. https://doi.org/10.2196/14340

    Article  PubMed  PubMed Central  Google Scholar 

  55. 55.

    Hazlehurst BL, Lawrence JM, Donahoo WT, Sherwood NE, Kurtz SE, Xu S, et al. Automating assessment of lifestyle counseling in electronic health records. Am J Prev Med. 2014;46(5):457-64. https://doi.org/10.1016/j.amepre.2014.01.001.

    Article  PubMed  PubMed Central  Google Scholar 

  56. 56.

    Chen J, Lalor J, Liu W, Druhl E, Granillo E, Vimalananda VG, et al. Detecting Hypoglycemia Incidents Reported in Patients’ Secure Messages: Using Cost-Sensitive Learning and Oversampling to Reduce Data Imbalance. J Med Internet Res. 2019;21(3):e11990. https://doi.org/10.2196/11990

    Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Pathak RD, Schroeder EB, Seaquist ER, Zeng C, Lafata JE, Thomas A, et al. Severe Hypoglycemia Requiring Medical Intervention in a Large Cohort of Adults With Diabetes Receiving Care in U.S. Integrated Health Care Delivery Systems: 2005-2011. Diabetes Care. 2016;39(3):363-70. https://doi.org/10.2337/dc15-0858.

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-64. https://doi.org/10.1056/NEJMsa020703.

    Article  PubMed  Google Scholar 

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Acknowledgments

Contributors: The ACT Study team consists of members from Duke University, Durham, NC (L. Ebony Boulware); members from the Johns Hopkins University, Baltimore, MD (Hanan Aboumatar, Michael Albert, Jessica Ameling, Lee Bone, Kathryn Carson, Jeanne Charlston, Lisa Cooper, Deidra Crews, Patti Ephraim, Peter Fagan, Debra Gayles, Raquel Greer, Kimberly Gudzune, Haera Han, Felicia Hill-Briggs, David Levine, LaPricia Lewis-Boyer, Richard Matens, Linda Mobula, Debra Roter, Hema Ramamurthi, Valerie Sneed, Rachel Thornton, Jennifer Wolff); and members of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities Community Advisory Board (Debra Hickman, Leon Purnell, Michelle Simmons, Annette Fisher); the University of Rochester, Rochester, NY (Gary Nohornha); Rush University (Stephanie Fitzpatrick); the University of Texas, Austin, TX (Miyong Kim); the Unviversity of Maryland, Baltimore, MD (Jeffrey Barbers); and the Brooklyn Hospital Center, Brooklyn, NY (Tanyka Sam).

Funding

Dr. Pilla was supported by the Johns Hopkins KL2 Clinical Research Scholars Program (KL2TR003099). The ACT study was supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (1P50HL105187).

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Correspondence to Scott J. Pilla MD, MHS.

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Pilla, S.J., Park, J., Schwartz, J.L. et al. Hypoglycemia Communication in Primary Care Visits for Patients with Diabetes. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-020-06385-x

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KEY WORDS

  • diabetes mellitus
  • hypoglycemia
  • primary care
  • communication
  • Achieving Blood Pressure Control Together (ACT) study