VA Hospitals Often Send Seniors Off With Unnecessary Diabetes Tx

Half of older diabetic patients discharged from Veterans Affairs hospitals with intensified treatment regimens were unlikely to benefit from them, researchers determined.

Among more than 16,000 hospitalized veterans 65 and older, 1,626 were discharged with an increase in their diabetes regimen — most often with insulin or sulfonylureas classified as high-risk, reported Timothy Anderson, MD, MAS, of Beth Israel Deaconess Medical Center in Brookline, Massachusetts, and colleagues in JAMA Network Open.

Of this latter group, 49% were either already at their target HbA1c level at admission or had limited life expectancy, and thus did not genuinely need the intensified treatment, the researchers said.

Another 20% of those who were discharged with an intensification were deemed to only gain a potential benefit.

Diabetes medication intensity was defined as adding a new medication to the patient’s diabetes regimen or more than a 20% increase in the dose of an existing medication. Among those discharged with intensified treatment, half received a new insulin and more than a third had sulfonylurea doses raised. Prior to hospital admission, none of the individuals included in the study were on insulin.

“We hope our study will help clinicians move beyond considering only the short term blood sugar values collected during hospitalization and towards a more patient centered decision making process that considers patients’ long term likelihood of benefit and the potential risks of new medication exposures,” Anderson explained to MedPage Today.

“The findings of this study are similar to our prior research on high blood pressure medication changes at hospital discharge and so supports the fact that when they decide to change chronic diabetes or high blood pressure medications, doctors may often be responding to short-term measurements taken in the hospital, rather than the long-term context of a patient’s health,” he said.

Anderson said his group got the idea for the study from seeing many changes to patients’ medications at discharge, including diabetes drugs, many of which may confuse patients. “Thus we wanted to understand how common these changes are and whether they are likely to benefit patients.”

Anderson’s point falls in line with current guidelines from the American Diabetes Association, which suggests a higher glycemic target for healthy older adults — HbA1c under 7.5%. And for older patients with poorer health or reduced cognitive functions, an even less stringent glycemic goal of 8.0% to 8.5% is recommended. This is largely due to the increased risks associated with hypoglycemia, which can lead to potentially fatal falls in frailer older adults. The researchers explained they defined insulin and sulfonylurea as “high risk intensifications” because they’re more strongly tied to severe hypoglycemic events than other diabetes medications.

Not surprisingly, preadmission HbA1c was significantly associated with rates of intensification, as those with an elevated measure of 9% or higher had markedly higher rates of intensification (odds ratio 7.06, 95% CI 5.01-9.94). However, even those who were considered to have a “controlled” HbA1c mostly in line with the guidelines — 7% to 8.9% — also had significantly higher risk of intensification (OR 2.46, 95% CI 2.03-2.98) versus those with tight glycemic control (HbA1c under 7%).

Even those with just a moderately elevated inpatient blood glucose had much higher odds of intensification (OR 2.74, 95% CI 2.20-3.42). Another factor tied to higher rate of intensification was inpatient corticosteroids (OR 1.24, 95% CI 1.04-1.49).

“Ultimately we want to achieve long-term diabetes control while avoiding the risks of unnecessary changes, especially following hospitalization when patients are uniquely vulnerable from medication harms as they recover from acute illnesses,” Anderson explained to MedPage Today.

In an accompanying commentary, Eduard Vasilevskis, MD, MPH, of Vanderbilt University Medical Center in Nashville, said the study highlights the need to improve treatment-related decision-making at hospital discharge.

“[I]npatient clinicians may be currently too focused on the numbers,” he wrote.

Vasilevskis called for randomized clinical trials to define appropriate intensification of diabetes regimens during an acute care transition, as well as more research on “deprescribing” for older patients.

He also recommended that clinicians who decide to intensify an older patients’ regimen upon discharge should avoid high-risk medications such as insulin and sulfonylureas if possible. Continued follow-up and post-discharge monitoring of these patients via telehealth and continuous glucose monitoring are also beneficial, he said.