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Original Investigation | Less Is More

Assessing Potential Glycemic Overtreatment in Persons at Hypoglycemic Risk

Chin-Lin Tseng, DrPH1,2; Orysya Soroka, MS1; Miriam Maney, MA, CPHQ1; David C. Aron, MD, MS3,4; Leonard M. Pogach, MD, MBA1,2
[+] Author Affiliations
1Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey
2Department of Preventive Medicine, Rutgers University–New Jersey Medical School, Newark
3Department of Medicine, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio
4Interprofessional Implementation Research, Evaluation and Clinical Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
JAMA Intern Med. 2014;174(2):259-268. doi:10.1001/jamainternmed.2013.12963.
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Importance  Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment.

Objective  To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia.

Design, Setting, and Participants  Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009.

Main Outcomes and Measures  Intensive control was defined as the last hemoglobin A1c (HbA1c) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA1c less than 7.0% in patients who were aged 75 years or older who had a serum creatinine value greater than 2.0 mg/dL or had a diagnosis of cognitive impairment or dementia. We also assessed the rates in patients with other significant medical, neurologic, or mental comorbid illness. Variation in rates of possible glycemic overtreatment was evaluated among 139 Veterans Health Administration facilities grouped within 21 Veteran Integrated Service Networks.

Results  There were 652 378 patients who received insulin and/or a sulfonylurea with an HbA1c test result. Fifty percent received sulfonylurea therapy without insulin; the remainder received insulin therapy. We identified 205 857 patients (31.5%) as the denominator for the primary outcome measure; 11.3% had a last HbA1c value less than 6.0%, 28.6% less than 6.5%, and 50.0% less than 7.0%. Variation in rates by Veterans Integrated Service Network facility ranged 8.5% to 14.3%, 24.7% to 32.7%, and 46.2% to 53.4% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The magnitude of variation by facility was larger, with overtreatment rates ranging from 6.1% to 23.0%, 20.4% to 45.9%, and 39.7% to 65.0% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The maximum rate was nearly 4-fold compared with the minimum rates for HbA1c less than 6.0%, followed by 2.25-fold for HbA1c less than 6.5% and less than 2-fold for HbA1c less than 7.0%. When comorbid conditions were included, 430 178 patients (65.9%) were identified as high risk. Rates of overtreatment were 10.1% for HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%.

Conclusions and Relevance  Patients with risk factors for serious hypoglycemia represent a large subset of individuals receiving hypoglycemic agents; approximately one-half had evidence of intensive treatment. A patient safety indicator derived from administrative data can identify high-risk patients for whom reevaluation of glycemic management may be appropriate, consistent with meaningful use criteria for electronic medical records.

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Figure 1.
Overtreatment Rates by Veterans Integrated Service Network (VISN)

The denominator population is patients 75 years or older; serum creatinine level, ≥2.0 mg/dL; or diagnosis of cognitive impairment or dementia. The VISNs are in ranking based on overtreatment rates (hemoglobin A1c [HbA1c] <7.0%). To convert serum creatinine to micromoles per liter, multiply by 88.4; HbA1c to a proportion of total Hb, multiply by 0.01.

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Figure 2.
Facility Variation in Overtreatment Rates by Veterans Integrated Service Network (VISN)

The denominator population: patients 75 years or older; serum creatinine level, ≥2.0 mg/dL; or diagnosis of cognitive impairment or dementia. The VISNs are in ranking based on overtreatment rate for hemoglobin A1c (HbA1c) <7.0%. Facilities (A), (B), and (C) refer to positive deviants identified in Figure 3. To convert serum creatinine to micromoles per liter, multiply by 88.4; HbA1c to a proportion of total Hb, multiply by 0.01.

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Figure 3.
Scatterplot of Difference (δ) by Outlier Status for Different Hemoglobin A1c (HbA1c) Thresholds

aDifference between overtreatment rates of a facility and its corresponding Veterans Integrated Service Network.bOutlier status (based on statistical testing described in the Methods section). Facilities (A), (B), and (C) are positive deviants. Neg indicates potential negative deviant; No, nonoutlier; and Pos, potential positive deviant. To convert HbA1c to a proportion of total Hb, multiply by 0.01.

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