Hypoglycemia Communication in Primary Care Visits for Patients with Diabetes



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.


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


Qualitative study


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


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.


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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Figure 1


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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).


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