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This project aimed to reduce the number of high-risk patients prescribed insulin and/or sulfonylurea with glycated haemoglobin (HgbA1c) <7% in San Francisco Veterans Affairs Health Care System Medical Practice Clinic (SFVAHCS MPC).
Diabetes is a common disease where tight glycaemic control as assessed by HgbA1c must be balanced with the inherent risk of hypoglycaemic events caused by medications like sulfonylureas and insulin.1–3 In a previous study conducted in US veterans, a lower HbA1c of 6.9% compared with 8.4% had minimal impact on improving health, while increasing risk of at least one hypoglycaemic event (8.5% vs 3.1%).4 Elderly patients, especially those with cognitive or renal impairment, are at highest risk of hypoglycaemic events, which often result in decreased quality of life, loss of consciousness, seizures and altered mental status.5 6 Insulin (13.9%) and oral hypoglycaemic agents (10.7%) were among the four most commonly implicated medications requiring hospitalisations for adverse drug reactions.5 Recently, the Veterans Affairs (VA) adapted recommendations from the American Diabetes Association and the American Geriatrics Society’s Choosing Wisely initiative to avoid using these medications in high-risk patients with HbA1c <7.0%.7 8 Unfortunately, healthcare systems lack clear guidelines on how to enact these recommendations.
A total of 62 patients were identified November 2016 using an internal VA clinical performance dashboard. Eligible patients received primary care at SFVAHCS MPC, had diabetes, were prescribed insulin and/or sulfonylurea, had an HgbA1c <7% within the past 6 months and had at least one risk factor for hypoglycaemia: age ≥75, cognitive impairment and/or estimated glomerular filtration rate (eGFR) <30. A total of 34 patients were excluded due to recent insulin/sulfonylurea medication change (n=21), updated HgbA1c >7% (n=8), no longer receiving primary care at SFVAHCS MPC (n=3) and death (n=2). A total of 28 patients met inclusion criteria. Patients …
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