Assessing Potential Glycemic Overtreatment in Persons at Hypoglycemic Risk

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 A(1c) (HbA(1c)) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA(1c) 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 HbA(1c) 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 HbA(1c) 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 HbA(1c) 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 HbA(1c) 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 HbA(1c), less than 6.0%, followed by 2.25-fold for HbA(1c) less than 6.5% and less than 2-fold for HbA(1c) 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 HbA(1c) 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.