Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

Stasinopoulos, Jacquelina; Wood, Stephen; Bell, John; Manski‐Nankervis, Jo‐Anne; Hogan, Michelle; Sluggett, Janet K.

doi:10.1016/j.jamda.2021.04.013

Cited by 18 publications

(16 citation statements)

References 64 publications

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“…Other studies have shown that frail NH residents with diabetes are often overtreated to HbA1c levels below recommended targets, that insulin and other high-risk antihyperglycemic agents are overused in NHs, and that SSI use is prevalent and persistent in some for-profit NHs. 20,27,28 Our results add to this literature by…”

Section: Discussionsupporting

confidence: 81%

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Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes

Lam

Gan

Nguyen

et al. 2022

J American Geriatrics Society

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Background Guidelines discourage sliding scale insulin (SSI) use after the first week of a nursing home (NH) admission. We sought to determine the prevalence of SSI and identify factors associated with stopping SSI or transitioning to another short‐acting insulin regimen. Methods In an observational study from October 1, 2013, to June 30, 2017 of non‐hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week, we compared the weekly prevalence of SSI versus two other short‐acting insulin regimens – fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) – from week 2 to week 12 of admission. Among those on SSI in week 2, we examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty‐related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes‐related factors (e.g., HbA1c, long‐acting insulin use, hyperglycemia, and hypoglycemia). Results In week 2, 21% of our cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate–severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes‐related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non‐SSI short‐acting insulin regimen than frailty‐related factors. Conclusions SSI is the most common method of administering short‐acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.

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Section: Discussionsupporting

confidence: 81%

“…18 Nevertheless, previous studies suggest that SSI is common in for-profit NHs in some states even months after NH admission, with a median prevalence of 38%. [18][19][20] Whether SSI use in NHs is prevalent nationally and how SSI use evolves week by week from the time of admission is unknown.…”

Section: Introductionmentioning

confidence: 99%

Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes

Lam

Gan

Nguyen

et al. 2022

J American Geriatrics Society

View full text Add to dashboard Cite

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“…The rates of overtreatment we observed are consistent with other published studies among LTC residents in Canada and the United States. [4][5][6][7][8] 8 We found higher rates of deprescribing compared to a recent study in US LTC homes, which may be explained by our longer follow-up period. 8 Limitations included missing HbA1c data for around 30% of residents with diabetes.…”

Section: Discussioncontrasting

confidence: 62%

Rates of overtreatment and deprescribing of antihyperglycemics among long‐term care residents in British Columbia

Pan

Tejani

Logan

et al. 2023

J American Geriatrics Society

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“…However, since the short‐acting insulin category only made up 16% of our cohort, we believe this effect is unlikely to substantially impact our overall results. Finally, as recently highlighted by Stasinopoulous et al, 20 the lack of a standardized definition for over‐ and undertreatment complicates study in this area.…”

Section: Discussionmentioning

confidence: 99%

“…We have previously shown that overtreatment of diabetes occurs in 14% or greater VA NH residents 19 . A recent systematic review reported that among NH residents worldwide, rates of overtreatment and undertreatment vary widely (5%–86% and 1%–35%, respectively) 20 . Although one previous study examined deintensification practices among NH residents with life expectancy <6 months or advanced dementia, 21 little is known about deintensification practices in a general population of NH residents.…”

Section: Introductionmentioning

confidence: 99%

Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes

Lederle

Steinman

Jing

et al. 2022

J American Geriatrics Society

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Background Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting. Methods We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose‐lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c. Results Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long‐acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14–1.65 and OR 1.35, 95% CI 1.10–1.66, respectively). Severe functional impairment (MDS‐ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56–0.95). Hypoglycemia was not associated with decreased odds of overtreatment. Conclusions Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification.

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Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

Cited by 18 publications

References 64 publications

Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes

Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes

Rates of overtreatment and deprescribing of antihyperglycemics among long‐term care residents in British Columbia

Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes

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