Tool may help stratify risk for hypoglycemia-related ED and hospital use

The hypoglycemia risk stratification tool is based on six variables: previous episodes of hypoglycemia-related hospital utilization, insulin use, sulfonylurea use, ED use in the previous year, chronic kidney disease stage, and age.


A recently developed risk stratification tool may help categorize the likelihood of ED or hospital use due to hypoglycemia over a 12-month period in patients with type 2 diabetes, a new study has found.

Researchers developed a classification tree according to potential predictors of hypoglycemia-related ED or hospital use and transcribed the resulting model into a risk stratification tool. The tool was then tested in one internal sample and two independent external samples. A split sample of 206,435 patients with type 2 diabetes from Kaiser Permanente Northern California was used for development and for internal testing. External testing was done in a sample of 1,335,966 patients with type 2 diabetes from the Veterans Health Administration and 14,972 patients with type 2 diabetes from Group Health Cooperative. Main outcome measures were hypoglycemia-related ED or hospital use over 12 months of follow-up. The study results were published online Aug. 21 by JAMA Internal Medicine.

In the derivation sample of 165,148 patients, the mean age was 63.9 years and 47.6% were women, and the crude annual rate of at least one ED or hospital encounter related to hypoglycemia was 0.49%. The hypoglycemia risk stratification tool requires six patient-specific clinical variables: number of previous episodes of hypoglycemia-related utilization (0, 1 to 2, or ≥3), insulin use (yes or no), sulfonylurea use (yes or no), ED use in the previous year (<2 times or ≥2 times), chronic kidney disease stage (dialysis or stage 4 or 5), and age younger than 77 years (yes or no). Predicted 12-month risk for any hypoglycemia-related utilization was categorized as high (>5%), intermediate (1% to 5%), or low (<1%). A total of 2.0% of the internal validation sample were categorized as high risk, 10.7% were categorized as intermediate risk, and 87.3% were categorized as low risk. Resulting rates of hypoglycemia-related resource use over 12 months were 6.7%, 1.4%, and 0.2%, respectively. Good discrimination was found in all of the validation samples.

The researchers noted that model development did not include secondary discharge diagnoses for hypoglycemia and that the tool did not consider severe hypoglycemia that occurred outside the health care system, among other limitations. However, they concluded that the tool is a practical method of stratifying risk for hypoglycemia-related ED or hospital use over 12 months in patients with type 2 diabetes and could be integrated into the electronic medical record. They said that the tool should not be used to estimate probability for an individual patient but suggested that health care systems could use it to develop a two-level intervention, reserving intensive interventions for high-risk patients and less intensive interventions for intermediate-risk patients.

“Quality improvement and impact studies are needed to evaluate whether and how implementation of this hypoglycemia risk stratification tool may influence clinician behavior, patient decision making, drug safety, and hypoglycemia incidence,” the authors wrote. “Future research is needed to develop patient-centered and cost-effective interventions to reduce hypoglycemia risk in those identified as being at high risk for hypoglycemia.”