Hypoglycemia from overtreatment is a serious but seldom recognized complication in older adults with type 2 diabetes. A new decision support tool developed by the Endocrine Society can help primary care providers avoid overtreatment and cut the risk of hypoglycemic events in these patients.

The use of a clinical decision support tool can reduce the risk of hypoglycemia among older patients with type 2 diabetes, according to a new study spearheaded by the Endocrine Society.

Many studies have shown that too often, physicians who are treating diabetes are so focused on achieving glycemic control goals that they overlook the risk of hypoglycemia in older adults with type 2 diabetes, according to Jeffrey B. Boord, MD, MPH, chief quality and safety officer at of Parkview Health in Fort Wayne, Ind., and lead author of the HypoPrevent study, which was published in the Journal of the American Geriatric Society. 

“We know from the literature that hypoglycemia in older adults with type 2 diabetes is very common and creates morbidity,” Boord says. “However, it is seldom addressed and mitigated in clinical practice.”

“We are excited about this study because, up to this point, there really have not been well-designed, pragmatic studies demonstrating how you can do an intervention that will actually reduce the rate or risk of hypoglycemia in a real-world setting in primary care. Because this intervention was so successful, we hope that our clinical decision support tool could be adopted for use in other primary care settings to lower the risk of hypoglycemia and improve the overall well-being of older adults with diabetes.”

Jeffrey B. Boord, MD, MPH, chief quality and safety officer, Parkview Health, Fort Wayne, Ind.

The literature shows that older adults often remain on the same medications even after they have had a hospitalization or emergency department visit related to a severe hypoglycemic event. “We screen patients for other complications of diabetes, like eye disease, foot problems, and kidney disease. How about screening them for risk of hypoglycemia?” Boord says.

Reducing Overtreatment

The HypoPrevent study tested whether the use of a clinical decision support tool and shared decision-making could encourage clinicians to give greater attention to hypoglycemia risk. The study involved 94 at-risk patients at Pottstown Medical Specialists, a five-site primary care practice in Pennsylvania. The patients were 65 years or older with type 2 diabetes being treated with medications that can cause low blood glucose, such as insulin or sulfonylureas.

During three clinic visits over six months, the clinicians used the online tool and shared decision-making to assess hypoglycemic risk, set individualized HbA1c goals, and adjust diabetes medications. The study found that use of the support tool decreased the population at risk of hypoglycemic events by almost 50%. Insulin or sulfonylurea use was decreased or eliminated in 20% of the patients.

The patients also reported a reduction in non-severe hypoglycemic events that led to improvements in their daily functioning, emotional well-being, diabetes management, sleep disruption, and work productivity.

Development of the Tool

The study team developed the “Hypoglycemia Reduction Clinical Decision Support Tool” based on the literature, including Endocrine Society clinical practice guidelines on treating diabetes in older adults and managing patients at high risk for hypoglycemia, as well as American Diabetes Association care standards.

The support tool guides the clinician through questions to ask, care plan development, and provides recommended actions, including pathways to de-escalate treatment if the patient is experiencing hypoglycemic episodes. “It provides guidance,” Boord says. “The goal is not to tell people exactly what to do, but to provide questions to ask and guideline-based material that will help inform decisions around hemoglobin HbA1c targets and what to do about hypoglycemia.

We got permission to use an outstanding de-escalation algorithm from deprescribing.org.”

Boord says that the study achieved its positive effect by involving not only physicians, but also enlisting diabetes educators and nurses “to ask questions about hypoglycemia and have a meaningful discussion with patients about it. We believe a lot of the effect is just awareness, asking patients about the problem and educating them about it.”

Patients were asked to complete the Treatment Related Impact Measure — Hypoglycemic Events (TRIM-HYPO) survey, an assessment developed by the Mapi Research Trust that is available at no cost for clinical use. “The TRIM-HYPO assessments gave patients a way to identify how non-severe hypoglycemic events were affecting their quality of life,” Boord says.

Hypoglycemia Prevention Initiative

The HypoPrevent study is part of the Hypoglycemia Prevention Initiative, a multi-year joint effort of the Endocrine Society and Avalere Health to determine best practices in primary care to reduce the impact of hypoglycemia on patients over 65 with type 2 diabetes who use insulin and/or a sulfonylurea, have a recent A1c <7%, and are at increased risk of hypoglycemia.

The Endocrine Society plans to disseminate the tool widely, according to Robert W. Lash, MD, the Endocrine Society chief medical officer and a member of the study team: “We published the article in a major geriatrics journal so the results would be seen by the most relevant set of clinicians. We’ve also presented the data at the annual meeting of the Association of Diabetes Care and Education Specialists.”

“Primary care and endocrine healthcare providers see a significant number of older individuals with diabetes that are at high-risk for hypoglycemia,” says David C. Lieb, MD, professor of endocrinology and diabetes at Eastern Virginia Medical School. “We need better means for quickly identifying those patients, and for reducing their risk for hypoglycemia by appropriately adjusting their glycemic goals and avoiding overtreatment. The results from this study demonstrate that an easy-to-use clinical decision support tool can help providers to do just that and can improve patient-reported outcomes as well.” Lieb co-chaired the committee that wrote “Management of Individuals with Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline” but was not involved in the HypoPrevent Study.

“The goal is not to tell people exactly what to do, but to provide questions to ask and guideline-based material that will help inform decisions around hemoglobin HbA1c targets and what to do about hypoglycemia.”

Jeffrey B. Boord, MD, MPH, chief quality and safety officer, Parkview Health, Fort Wayne, Ind.

“We are excited about this study because, up to this point, there really have not been well-designed, pragmatic studies demonstrating how you can do an intervention that will actually reduce the rate or risk of hypoglycemia in a real-world setting in primary care,” Boord says. “Because this intervention was so successful, we hope that our clinical decision support tool could be adopted for use in other primary care settings to lower the risk of hypoglycemia and improve the overall well-being of older adults with diabetes.”

The Society has published the decision tool and a wealth of other treatment resources online at endocrine.org/hypoglycemia-prevention-initiative.

The other authors of this study are Deborah A. Koehn of VCU Stony Point Women’s Health in Richmond, Va.; Kathleen Marie Dungan of The Ohio State University in Columbus, Ohio; Amisha Wallia of Northwestern University Feinberg School of Medicine in Chicago, Ill.; Deborah Otcasek Lucas of Avalere Health and BridgingCare LLC in Washington, D.C.; Robert W. Lash and Mila N. Becker of the Endocrine Society in Washington, D.C.; and Lawrence D. Dardick of David Geffen School of Medicine at UCLA in Los Angeles, Calif.

The study was funded by Abbott Laboratories, Eli Lilly and Company, Merck, Novo Nordisk, and Sanofi.

Seaborg is a freelance writer based in Charlottesville, Va. In the September issue, he wrote about the importance of endocrinologists in treating steatotic liver disease in “Endocrine Targets.”