Improving Drug Therapy for Patients With Life‐Limiting Illnesses: Letʼs Take Care of Some Low Hanging Fruit

Self Cite

265

269

The pandemic of viral infection with the severe acute respiratory syndrome coronavirus-2 that causes COVID-19 disease has put the nursing home industry in crisis. The combination of a vulnerable population that manifests nonspecific and atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources for and availability of rapid, accurate testing and personal protective equipment, and lack of effective treatments for COVID-19 among nursing home residents have created a "perfect storm" in our countryʼs nursing homes. This perfect storm will continue as society begins to reopen, resulting in more infections among nursing home staff and clinicians who acquire the virus outside of work, remain asymptomatic, and unknowingly perpetuate the spread of the virus in their workplaces. Because of the elements of the perfect storm, nursing homes are like a tinderbox, and it only takes one person to start a fire that could cause many deaths in a single facility. Several public health interventions and health policy strategies, adequate resources, and focused clinical quality improvement initiatives can help calm the storm. The saddest part of this perfect storm is that many years of inaction on the part of policy makers contributed to its impact. We now have an opportunity to improve nursing homes to protect residents and their caregivers ahead of the next storm. It is time to reimagine how we pay for and regulate nursing home care to achieve this goal.

Section: Clinical Carementioning

confidence: 99%

COVID‐19 in Nursing Homes: Calming the Perfect Storm

Ouslander

Grabowski

2020

Self Cite

265

269

“…In addition, FS monitoring increases staff burden and staff‐resident contacts, which would be especially detrimental in the current severe acute respiratory syndrome coronavirus 2 pandemic. Thus, decreasing FS monitoring may represent “low hanging fruit”: a relatively straightforward change that may provide substantial benefits to NH residents 12,13 …”

Section: Introductionmentioning

confidence: 99%

“…Thus, decreasing FS monitoring may represent "low hanging fruit": a relatively straightforward change that may provide substantial benefits to NH residents. 12,13 Unfortunately, there is surprisingly little evidence to guide the optimal frequency of FS glucose monitoring in NH residents. Studies of FS monitoring in communitydwelling older adults with T2DM have been mixed, with patients on insulin receiving some benefit from routine FS monitoring but patients on noninsulin regimens receiving minimal benefit.…”

Section: Introductionmentioning

confidence: 99%

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

Jeon

Shi

Lee

et al. 2020

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.

“…24 Simplifying glycemic regimens and reducing unnecessary fingersticks represents a "low-hanging fruit" intervention that can reduce treatment burden and may improve resident well-being. 25 The primary strength of our study is that it is the first to examine fingerstick frequency stratified by cognitive impairment status across NHs nationally. Individuals with moderate/severe cognitive impairment represent an important subgroup at high risk for adverse events and are increasingly becoming a focus for deprescribing interventions.…”

Section: Discussionmentioning

confidence: 99%

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

Nguyen

Deardorff

Shi

et al. 2022

Background: Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels. Methods:We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/À metformin but no insulin), (4) long-acting insulin (+/À oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission. Results: Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation = 1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status.Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact). Conclusion: NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration Brian Nguyen and William James Deardorff contributed equally to this study as co-first authors.