Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

Abstract

IMPORTANCE Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. OBJECTIVE To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. MAIN OUTCOMES AND MEASURES Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. RESULTS Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A 1c (HbA 1c) level less than 7.0%, and 1044 (6%) had an HbA 1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA 1c , while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA 1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA 1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. CONCLUSIONS AND RELEVANCE In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA 1c goal.

The Challenges of Diabetes Medication Management at Hospital Discharge in Older Adults

“…This last group had HbA 1c levels between 7.5% and 9.0% with a life expectancy of 5 or more years. Importantly, although Anderson et al 3 provide labels of benefit to the intensification categories, these labels are based on the expected treatment response when following the ADA guidelines for older adults 1 for a patient seen in the outpatient setting. Extrapolating benefit categories to the period of hospital discharge, although intuitive, lacks the same level of evidence found in the ADA guidelines.…”

“…For example, a major independent risk factor associated with medication intensification at discharge was an HbA 1c level greater than 9.0% (odds ratio, 7.06 [95% CI, 5.01-9.94]). 3 This suggests an attempt by inpatient clinicians to alter the course of a measure that reflects outpatient glucose control. Similarly, inpatient clinicians may be extrapolating inpatient treatment guidelines to the postdischarge period.…”

“…Similarly, inpatient clinicians may be extrapolating inpatient treatment guidelines to the postdischarge period. The study by Anderson et al 3 found that the strongest intensification risk factor was the presence of severely elevated glucose during hospitalization (odds ratio, 9.46 [95% CI, 7.11-12.59]), supporting the possibility of an effort to continue control of hyperglycemia in the postdischarge period.…”

“…Considering the research by Anderson et al, 3 it is possible and even probable that inpatient clinicians unnecessarily intensify diabetes treatments at discharge. 3 Inpatient clinicians are appropriately concerned about outcomes among their patients with elevated HbA 1c levels and ongoing hyperglycemia. However, preventing potentially unnecessary intensification will require new evidence and continued improvements during care transitions.…”

“…The median number of medications for this cohort was 9, with one-fourth of patients having 12 or more medications. 3 Ongoing hospital-based research may help determine the safety of deprescribing diabetes medications, especially among older patients and those with HbA 1c levels less than 8.0% to 8.5%. 7 Third, if a clinician decides to intensify medications, measures should be taken to avoid high-risk medications when possible (eg, insulin and sulfonylureas).…”