1 in 10 older inpatients with diabetes discharged with intensified medication regimen
Nearly half of those who had their diabetes medications intensified after hospitalization had already reached outpatient blood glucose goals or had limited life expectancy, according to a recent Veterans Health Administration study.
For older inpatients with diabetes, discharging clinicians should consider long-term glucose control and life expectancy in addition to inpatient blood glucose readings to avoid excessive medication intensifications at discharge, a study suggested.
Researchers retrospectively looked at patients ages 65 years and older with diabetes not previously requiring insulin who were hospitalized in Veterans Health Administration hospitals for common medical conditions between 2012 and 2013. They assessed how often the patients were discharged with intensified diabetes medications, defined as a new or higher-dose medication at discharge than was being taken prior to hospitalization, as well as the likelihood of benefit associated with these intensifications. Results were published March 24 by JAMA Network Open.
Of 16,178 patients (mean age, 73 years; 98% men), 8,535 (53%) had a preadmission HbA1c level less than 7.0%, and 1,044 (6%) had an HbA1c level greater than 9.0%. Nearly 70% of patients were taking one or more diabetes medications prior to hospitalization, with metformin and sulfonylureas the most commonly used. Overall, 1,626 patients (10%) were discharged with intensified diabetes medications, including 781 (5%) with new insulin use and 557 (3%) with intensified sulfonylureas.
Nearly half of those receiving intensifications (n=791; 49%) were classified by the researchers as unlikely to benefit due to limited life expectancy or a preadmission HbA1c level less than 7.5%. Twenty percent (n=329) had potential benefit (i.e., preadmission HbA1c level greater than 9.0%). The remaining 31% were classified as indeterminate benefit (i.e., HbA1c level between 7.5% and 9.0% with a life expectancy of five years or more). Higher preadmission HbA1c levels and inpatient blood glucose levels were associated with intensified diabetes medications at discharge. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3% to 4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15% to 26%) for those with severely elevated inpatient blood glucose levels.
Among other limitations, pharmacy records allowed for identification of dose changes for oral medications but did not accurately reflect changes to insulin dosing; therefore, the study excluded patients taking insulin prior to hospitalization, the authors noted. “Improving diabetes care for hospitalized older adults will require efforts to move beyond treating elevated inpatient numbers and toward patient-centered decision-making that considers long-term benefits and the risks of potentially unnecessary medication intensifications,” they concluded.
The results demonstrate that inpatient clinicians “may be currently too focused on the numbers” and trying to reconcile outpatient and inpatient American Diabetes Association guidelines during acute care transitions, an accompanying editorial noted. They may be responding to outpatient guidelines for glucose control while also extrapolating inpatient treatment guidelines to the postdischarge period, possibly in an effort to continue control of hyperglycemia, the editorial said.
“Inpatient clinicians are appropriately concerned about outcomes among their patients with elevated HbA1c levels and ongoing hyperglycemia. However, preventing potentially unnecessary intensification will require new evidence and continued improvements during care transitions,” the editorialist wrote.