BACKGROUND/OBJECTIVES
To determine the hypo- and hyper-glycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for Hemoglobin A1c (HbA1c)<8% in frail older patients with diabets.
DESIGN/SETTING
Guideline Implementation in PACE (Program of All-Inclusive Care for the Elderly)
PARTICIPANTS
All patients in the Before (10/02–12/04, n=338), Early (1/05–6/06, n=289) and Late phases of guideline implementation (7/06–12/08, n=385) with a diagnosis of diabetes mellitus and at least one HbA1c measurement.
INTERVENTION
Clinician education in 2005 with annual monitoring of the proportion of each clinician’s patients with diabetes with HbA1c<8%.
MEASUREMENTS
Hypoglycemia (Blood sugar or BS<50), hyperglycemia (BS>400) and severe hypoglycemia (Emergency room or ER visit for hypoglycemia)
RESULTS
Before, Early and Late groups were similar in mean age, race/ethnicity, comorbidity and functional dependency. Antihyperglycemic medication use increased with more patients using metformin (28% Before versus 42% Late, p<0.001) and insulin (23% Before versus 34% Late, p<0.001), with more patients achieving the AGS glycemic target of HbA1c<8% (74% Before versus 84% Late, p<0.001). Episodes of hyperglycemia (per 100 person-years) decreased dramatically (159 Before versus 46 Late, p<0.001) and episodes of hypoglycemia were unchanged (10.1 versus 9.3, p=0.50). Episodes of severe hypoglycemia were increased in the Early period (1.1 Before versus 2.9 Early, p=0.03).
CONCLUSION
Implementing the AGS glycemic control guideline for frail elders led to fewer hyperglycemic episodes, but more severe hypoglycemic episodes requiring ER visits in the Early implementation period. Future glycemic control guideline implementation efforts should be coupled with close monitoring for severe hypoglycemia in the early implementation period.