Hypoglycemia Communication in Primary Care Visits for Patients with Diabetes

Journal of General Internal Medicine (2021)Cite this article

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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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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Affiliations

  1. Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Scott J. Pilla MD, MHS, Jenny Park BA, Jessica L. Schwartz MD, MHS, Michael C. Albert MD, FACP, Nisa M. Maruthur MD, MHS, Mary Catherine Beach MD, MPH & Raquel C. Greer MD, MHS

  2. Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA

    Scott J. Pilla MD, MHS, Patti L. Ephraim MPH, Nisa M. Maruthur MD, MHS, Mary Catherine Beach MD, MPH & Raquel C. Greer MD, MHS

  3. Johns Hopkins Community Physicians, Johns Hopkins University, Baltimore, MD, USA

    Michael C. Albert MD, FACP

  4. Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Patti L. Ephraim MPH, Nisa M. Maruthur MD, MHS & Raquel C. Greer MD, MHS

  5. Division of General Internal Medicine, Duke University, Durham, NC, USA

    L. Ebony Boulware MD, MPH

  6. Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Nestoras N. Mathioudakis MD, MHS

  7. Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Mary Catherine Beach MD, MPH

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  1. Scott J. Pilla MD, MHS
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  2. Jenny Park BA
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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