A Quality Improvement Program to Reduce Potential Overtreatment of Diabetes Among Veterans at High Risk of Hypoglycemia

Abstract

Background.. Intensive glycemic control confers increased risk of hypoglycemia and little benefit among older individuals with diabetes. The aim of this quality improvement project was to reduce the number of patients treated to A1C levels that might confer greater risk than benefit (i.e., potential overtreatment) in the VA New England Healthcare System.Methods.. A provider report and clinical reminder were created to identify potentially overtreated patients and prompt clinicians to consider treatment de-intensification. Potentially overtreated patients were defined as those on insulin or a sulfonylurea whose most recent A1C was <7.0% and who were >74 years of age or diagnosed with dementia or cognitive impairment. The numbers of patients screened and whose treatment was de-intensified using the clinical reminder were counted from January to December 2014. The number of high-risk veterans at baseline was compared with that 6 and 18 months after implementation using t tests.Results.. A total of 2,830 patients were screened using the clinical reminder; 9.6% had their glycemic treatment de-intensified. Among the 261 patients reporting hypoglycemia, 37% had their treatment de-intensified. Higher percentages of patients had treatment de-intensified when reported symptoms were more severe. The monthly average in the high-risk cohort declined from baseline by 18% at 6 months and by 22% at 18 months (both P <0.005).Conclusions.. A clinical reminder helps clinicians identify and reduce the number of potentially overtreated patients. The large number of screened patients whose treatment was not de-intensified suggests that a clinical reminder should be combined with provider education, national guidelines, and performance measures aligned in the interest of reducing potential overtreatment.

<p>De-Intensification Of Blood Glucose Lowering Medication In People Identified As Being Over-Treated: A Mixed Methods Study</p>

“…This study shows that de-intensification of glucose-lowering medication occurred in more than half of the patients (56.3%), one year after detection of possible overtreatment. This is more than in previously published studies, with percentages ranging from 9.6% to 17.5%14,25,26 and could be explained by the fact that in two of these studies no notification of possible overtreatment was used 14,25. Another possibility is the latter studies were conducted between 2011 and 2014 before individualising treatment target was recommended in international guidelines 13–18,23.…”

Using Shared Decision-Making to Address Possible Overtreatment in Patients at High Risk for Hypoglycemia: The Veterans Health Administration’s Choosing Wisely Hypoglycemia Safety Initiative

“…In early 2014, the CW-HSI was implemented in VISN 1, a group of eight VHA medical centers in the Northeast region of the United States; their implementation leveraged the clinical alert and template for point-of-care identification (25). Since making the tools available for all VHA medical centers in January 2015, the online panel reports have been accessed 1,908 times by 481 VHA staff, and the template has been used 31,063 times for 20,051 VHA patients through March 2017.…”

The Association of Severe Hypoglycemia With Incident Cardiovascular Events and Mortality in Adults With Type 2 Diabetes

“…Greater provider awareness of severe hypoglycemia and the associated morbidity and mortality is needed (42). Hypoglycemia risk stratification tools have recently been developed (43), and although there have been some large-scale efforts to adjust glucose-lowering medications in high-risk individuals (44), the best approaches to reducing insulin dosage and hypoglycemia are still unknown (45). Further studies are needed to determine whether interventions to prevent hypoglycemia also reduce the risk of cardiovascular outcomes.…”