title: Assessing potential glycemic overtreatment in persons at hypoglycemic risk.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009.
  
  
  METHODS
  Intensive control was defined as the last hemoglobin A1c (HbA1c) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA1c 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 HbA1c 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 HbA1c 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 HbA1c 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 HbA1c 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 HbA1c less than 6.0%, followed by 2.25-fold for HbA1c less than 6.5% and less than 2-fold for HbA1c 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 HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%.
  
  
  CONCLUSIONS
  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.
authors: Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey 2Department of Preventive Medicine, Rutgers University-New Jersey Medical School, Newark.
authors: Chin-Lin
authors: CL
authors: Tseng
authors: Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey.
authors: Orysya
authors: O
authors: Soroka
authors: Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey.
authors: Miriam
authors: M
authors: Maney
authors: Department of Medicine, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio4Interprofessional Implementation Research, Evaluation and Clinical Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio.
authors: David C
authors: DC
authors: Aron
authors: Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey 2Department of Preventive Medicine, Rutgers University-New Jersey Medical School, Newark.
authors: Leonard M
authors: LM
authors: Pogach
mesh_terms: D000368:Aged; D001786:Blood Glucose / Q000378:metabolism; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007003:Hypoglycemia / Q000097:blood / Q000139:chemically induced* / Q000453:epidemiology; D007004:Hypoglycemic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D015994:Incidence; D007328:Insulin / Q000009:adverse effects / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D013453:Sulfonylurea Compounds / Q000009:adverse effects / Q000627:therapeutic use; D014481:United States / Q000453:epidemiology; D014728:Veterans
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; D013453:Sulfonylurea Compounds