Fingerstick Glucose Monitoring in Veterans Affairs Nursing Home Residents with Diabetes Mellitus

Abstract

BACKGROUND/OBJECTIVE Guidelines recommend less intensive glycemic treatment and less frequent glucose monitoring for nursing home (NH) residents. However, little is known about the frequency of fingerstick (FS) glucose monitoring in this population. Our objective was to examine the frequency of FS glucose monitoring in Veterans Affairs (VA) NH residents with diabetes mellitus, type II (T2DM). DESIGN AND SETTING National retrospective cohort study in 140 VA NHs. PARTICIPANTS NH residents with T2DM and older than 65 years admitted to VA NHs between 2013 and 2015 following discharge from a VA hospital. MEASUREMENTS NH residents were classified into five groups based on their highest hypoglycemia risk glucose‐lowering medication (GLM) each day: no GLMs; metformin only; sulfonylureas; long‐acting insulin; and any short‐acting insulin. Our outcome was a daily count of FS measurements. RESULTS Among 17,474 VA NH residents, mean age was 76 (standard deviation (SD) = 8) years and mean hemoglobin A1c was 7.6% (SD = 1.5%). On day 1 after NH admission, 49% of NH residents were on short‐acting insulin, decreasing slightly to 43% at day 90. Overall, NH residents had an average of 1.9 (95% confidence interval (CI) = 1.8–1.9) FS measurements on NH day 1, decreasing to 1.4 (95% CI = 1.3–1.4) by day 90. NH residents on short‐acting insulin had the most frequent FS measurements, with 3.0 measurements (95% CI = 2.9–3.0) on day 1, decreasing to 2.6 measurements (95% CI = 2.5–2.7) by day 90. Less frequent FS measurements were seen for NH residents receiving long‐acting insulin (2.1 (95% CI = 2.0–2.2) on day 1) and sulfonylureas (1.7 (95% CI = 1.5–1.8) on day 1). Even NH residents on metformin monotherapy had 1.1 (95% CI = 1.1–1.2) measurements on day 1, decreasing to 0.5 (95% CI = 0.4–0.6) measurements on day 90. CONCLUSION Although guidelines recommend less frequent glucose monitoring for NH residents, we found that many VA NH residents receive frequent FS monitoring. Given the uncertain benefits and potential for substantial patient burdens and harms, our results suggest decreasing FS monitoring may be warranted for many low hypoglycemia risk NH residents.

Fingerstick glucose monitoring by cognitive impairment status in Veterans Affairs nursing home residents with diabetes

“…While residents with higher levels of cognitive impairment received fewer fingersticks overall and in some GLM categories, the differences were relatively small suggesting that cognitive status may be a minor consideration in fingerstick monitoring decisions. Our results are aligned with a previous study in VA NH residents recently discharged from the hospital documenting the high burden of fingerstick monitoring 13 . We extend these results by demonstrating that fingersticks occur more frequently than recommended by guidelines across cognitive impairment levels in NH residents at day 31 after NH admission 4 …”

“…Our results are aligned with a previous study in VA NH residents recently discharged from the hospital documenting the high burden of fingerstick monitoring. 13 We extend these results by demonstrating that fingersticks occur more frequently than recommended by guidelines across cognitive impairment levels in NH residents at day 31 after NH admission. 4 Previous studies have found that individuals with severe cognitive impairment often receive high hypoglycemia risk GLMs, which can result in adverse events.…”

“…We classified residents as having T2DM if they had (1) hemoglobin A1c level of ≥6.5%, (2) used GLMs, or (3) International Classification of Diseases ( ICD ) code for T2DM ( ICD‐9 : 250.xx and 249.xx; ICD‐10 : E11.x and E09.x) in the year prior to NH admission up to 7 days after NH admission. During this time range, we also chose the HbA1c measured closest to day 31 of NH admission, either before or after 13,18,19 . We excluded those with diagnosis codes for Type 1 diabetes ( ICD‐9 : 250.x1 and 250.x3; ICD‐10 : E10.x) and NH hospice admissions.…”

“…4 However, a 2021 study of Veterans Affairs (VA) NHs found that fingersticks in individuals recently discharged from the hospital occurred much more frequently than recommended by guidelines. 13 This may be related to the high prevalence of sliding scale insulin usage that often persists well into a NH stay, standardized order sets that automatically order multiple fingersticks per day, and lack of awareness from clinicians that fingersticks are still being performed even after insulin is discontinued. 14 Individuals with cognitive impairment frequently receive GLMs and are treated to intensive glycemic targets despite the risks and lack of benefit.…”

“…The recommended frequency of fingersticks in NH‐specific diabetes guidelines varies but could range from once every 3 days for those only on long‐acting insulin to no routine monitoring for those on oral glucose lowering medications (GLM) 4 . However, a 2021 study of Veterans Affairs (VA) NHs found that fingersticks in individuals recently discharged from the hospital occurred much more frequently than recommended by guidelines 13 . This may be related to the high prevalence of sliding scale insulin usage that often persists well into a NH stay, standardized order sets that automatically order multiple fingersticks per day, and lack of awareness from clinicians that fingersticks are still being performed even after insulin is discontinued 14 …”