Clinical Support Tool, Shared Decision-Making Can Reduce Hypoglycemia in Older Adults

Results of the HypoPrevent study suggest the implementation of a low-cost, clinical decision support tool could reduce the risk of hypoglycemia from overtreatment in older adults with type 2 diabetes.

A quality improvement study including more than 90 adults aged 65 years and older with diabetes, results of the study indicate implementation of the study intervention, which leveraged a clinical decision support tool and shared decision-making, could cut the risk of hypoglycemia by nearly 50% and was associated with de-escalation of medications in 20% of patients.¹

“This study demonstrates that a low-cost clinical decision support tool, without the additional use of continuous glucose monitoring technology, can decrease the number of patients at high risk for hypoglycemia and reduce overtreatment with insulin and diabetes medications that cause hypoglycemia,” said study investigator Jeffrey B. Boord MD, MPH, of Parkview Health System and chair of the Endocrine Society’s Hypoglycemia Prevention Initiative Steering Committee.² “The patients in our study also reported significant reductions in the negative impact of hypoglycemia on their daily lives.”

A pre-post, single-arm study conducted at a 5-site primary care practice in Pennsylvania, the HypoPrevent study was launched by Boord and colleagues to evaluate whether a 2-component intervention in primary care setting could reduce overtreatment of type 2 diabetes and hypoglycemia. For inclusion in the study, patients needed to be 65 years of age or older, treated with insulin or sulfonylureas, and have an HbA1c less than 7.0%.¹

Per trial protocol, participants took part in 3 clinic visits over a 6-month period. During these visits, investigators used the clinical decision support tool and shared decision-making to assess hypoglycemic risk, set individualized HbA1c goals, and adjust medication. The clinical decision support tool used in the study provided clinicians with an instructional guide for the provider-patient encounter and provided information from all study visits, including prior SDM discussions, HbA1c goals, medications, HbA1c levels, and comorbidities, so information from prior visits was accessible to clinicians at each subsequent encounter.¹

The primary outcomes of interest for the study were impact of use on individualized HbA1c goals and/or modifications in the use of insulin or sulfonylureas, change in the number of study patients in the at-risk group for hypoglycemia before and after the intervention, and the impact of the use on non-severe hypoglycemia events. Investigators pointed out nonsevere hypoglycemic events were assessed using the Treatment Related Impact Measure—Hypoglycemic Events (TRIM-HYPO) survey.¹

A total of 94 patients were enrolled in the study. This cohort had a mean age of 74 years (range, 65-93), 57% were female, and 95% were White. Additionally, 61% had a disease duration of 10 or more years, 48% had chronic kidney disease, 51% reported insulin use at baseline, and 47% reported sulfonylurea use at baseline. Of the 94 patients enrolled in study, 80 completed all 3 study visits.¹

Upon analysis, results indicated 20% of participants decreased or eliminated use of insulin or sulfonylurea relative to baseline use. Results also indicated an HbA1c level before and after goal setting was obtained in 53% of the study cohort. Further analysis of this patient subgroup revealed the mean HbA1c increased by a mean of 0.53% (P <.0001) and the number of patients considered at-risk of hypoglycemia decreased by 46% (P <.0001). Investigators noted statistically significant reductions in the impact of hypoglycemia during daily activities were observed for both the total score and each of the 5 functional domains of TRIM-HYPO.¹

“Because this intervention was so successful, we hope that our clinical decision support tool could be adopted for use in other primary care settings to lower the risk of hypoglycemia and improve the overall well-being of older adults with diabetes,” Boord added.²

References:

1. Koehn DA, Dungan KM, Wallia A, et al. Reducing hypoglycemia from overtreatment of type 2 diabetes in older adults: The HypoPrevent study [published online ahead of print, 2023 Sep 21]. J Am Geriatr Soc. 2023;10.1111/jgs.18566. doi:10.1111/jgs.18566
2. Endocrine Society. Primary care intervention reduces hypoglycemia risk from type 2 diabetes overtreatment in older adults. Endocrine Society. September 27, 2023. Accessed September 29, 2023. https://www.endocrine.org/news-and-advocacy/news-room/2023/primary-care-intervention-reduces-hypoglycemia-risk-in-older-adults.