Study Examines Potential Over-Treatment of Hypoglycemia among Veterans with Diabetes Using VA Healthcare
Serious hypoglycemia is increasingly recognized as a public health issue that potentially impacts the quality of life for millions of persons with diabetes. Among persons 65 years and older, hypoglycemic agents (sulfonylureas and insulin) are the second most common medications associated with emergency room visits or hospitalizations. This study evaluated rates of intensive glycemic control as an indication of potential over-treatment among Veterans. Using VA administrative and laboratory data, investigators identified 652,378 Veterans who received sulfonylureas and/or insulin therapy in the VA healthcare system during FY09. The main outcome measure was an A1c < 7% in Veterans who were either 75 years or older, had renal insufficiency, or had a diagnosis of cognitive impairment or dementia. Sub-populations with medical, neurologic, and mental comorbid illnesses also were assessed in secondary analyses. Different thresholds to define intensive glycemic control were examined, using an A1c measure of < 6.0%, < 6.5%, or < 7.0%. Investigators also examined variations in over-treatment at VISN and VAMC levels (139 VA facilities across all VISNs).
- Intensive glycemic control, which may represent possible over-treatment, is common among older and/or sicker Veterans receiving VA healthcare. Of those Veterans who were either older than 75 years, and/or had renal insufficiency, and/or cognitive impairment (31% of the sample), about 1 in 10 patients had an A1c value below 6.0%, 29% below 6.5%, and half had values below 7.0%.
- Rates of possible over-treatment were only slightly lower using a more expansive definition of Veterans at high hypoglycemic risk, which included those with advanced diabetes-related complications, serious comorbid conditions, including cancer or serious neurological conditions, and cardiovascular or ischemic disease.
- Variation in over-treatment rates by VISN ranged from 9%-14% (for A1c < 6%) to 46%-53% (for A1c < 7%). The magnitude of variation by facility was larger, with rates ranging from 6%-23% (for A1c < 6%) to 40%-65% (for A1c < 7%).
- This study addressed possible or potential over-treatment. However, there may have been reasons why tight glycemic control was appropriate in some of these Veterans.
- There are social factors associated with hypoglycemia that were not ascertainable in the study data, such as social support, decreased health literacy and health numeracy, or shared decision-making.
- Veterans may have had additional lab tests and medication refills outside VA.
- Study results suggest the need for greater efforts to promote individualized treatment targets, especially for elderly Veterans with chronic conditions.
This study was partly funded through VA/HSR&D's Diabetes Quality Enhancement Research Initiative (QUERI) and HSR&D (IIR 08-355). Drs. Aron and Pogach are part of Diabetes-QUERI.
Tseng C, Soroka O, Maney M, Aron D, and Pogach L. Assessing Potential Glycemic Overtreatment in Persons at Hypoglycemic Risk. JAMA Internal Medicine December 9, 2013;e-pub ahead of print.