Study Examines Appropriate Prescribing for Veterans with Diabetes at High Risk for Hypoglycemia
Evidence is accumulating that older individuals with diabetes have little to gain from the treatment burdens of stringent blood glucose control. Moreover, some older patients with diabetes might be at risk for hypoglycemia-related harms from medications prescribed to meet standard hemoglobin A1c (HbA1c) targets. This study examined the beliefs of primary care healthcare professionals (PCPs) who might receive such recommendations. Investigators surveyed a national sample of 594 PCPs (physicians, nurse practitioners, and physician assistants) practicing in the VA healthcare system from October 2014 to December 2014. The survey included questions about practice characteristics, performance incentives, beliefs about decreasing use of inappropriate services, and demographics. In addition, study participants were asked to rate the level of difficulty they anticipated in following the Choosing Wisely recommendations to "avoid using medications other than metformin to achieve HbA1c less than 7.5% in most older adults."
- Almost half of the PCPs in this study reported that they would not worry about harms of tight control for an older patient with an HbA1c level of 6.5% who is at high risk of hypoglycemia.
- Of the 594 PCPs in this study, 161 (29%) agreed it would be somewhat or very difficult to follow the Choosing Wisely HbA1c recommendation for older adults.
- The PCPs who agreed that maintaining the HbA1c level below 7% would benefit the patient and who reported worrying about malpractice claims were more likely to report difficulty following the recommendations. Conversely, PCPs who reported worrying that the patient would be harmed with tight blood glucose control were less likely to report difficulty following HbA1c recommendations.
Providers need more explicit support in de-intensifying treatment for older Veterans with diabetes. VA recently launched a hypoglycemia safety initiative to decrease over-treatment among Veterans. To overcome provider misperceptions about the benefits of stringent blood glucose control – and concerns about negative repercussions following de-intensification of therapy, safety initiatives should be national and span multiple practices.
Dr. Kullgren was supported by an HSR&D Career Development Award, and Dr. Kerr was supported by VA HSR&D's Quality Enhancement Research Initiative (QUERI). Drs. Caverly, Fagerlin, Kullgren, Prenovost, and Kerr are part of HSR&D's Center for Clinical Management Research (CCMR).
Caverly T, Fagerlin A, Zikmund-Fisher B, Kirsh S, Kullgren J, Prenovost K, and Kerr E. Appropriate Prescribing for Patients with Diabetes at High Risk for Hypoglycemia: National Survey of Veterans Affairs Health Care Professionals. Research Letter. JAMA Internal Medicine. December 1, 2015;175(12):1994-96.