In Older Adults with T2D, Clinical Decision Support Tool Can Reduce Hypoglycemia

Among older adults treated with insulin or a sulfonylurea for type 2 diabetes (T2D), implementation of an easy-to-use, low-cost clinical decision support (CDS) tool plus shared decision making (SDM) discussions reduced the risk of hypoglycemic episodes by approximately 50% and reduced use of both medications in 20% of patients.¹

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The findings are from the HypoPrevent study,¹ a quality improvement study performed at a 5-site primary care practice in Pennsylvania that included 90 adults aged 65 years and older who were at significant risk of overtreatment-related hypoglycemia. Dangerously low serum glucose, study authors wrote, is a “serious but underrecognized complication among older adults with type 2 diabetes.”¹ And yet, medication is only rarely deintensified, placing a vulnerable population at high risk for adverse events, they added.¹ 

The results of HypoPrevent demonstrate that “a low-cost clinical decision support tool, without the additional use of continuous glucose monitoring technology,” can make a significant difference in quality of life for these older patients, observed study investigator Jeffrey B. Boord MD, MPH, of Parkview Health System and chair of the Endocrine Society’s Hypoglycemia Prevention Initiative Steering Committee”²

To evaluate the efficacy in the primary care setting of a 2-component intervention that used a CDS tool and SDM discussions to reduce overtreatment of older adults with T2D, Boord and colleagues screened patients aged 65 years and older, treated with insulin or sulfonylureas, who had an HbA1c of less than 7.0% across 5 practices.¹

During 3 clinic visits over the 6-month study period, investigators used the CDS tool and SDM to assess a participant’s risk of hypoglycemia, to set individualized HbA1c goals, and adjust medication.

The CDS tool used in the study featured a discussion guide for engaging participants in a SDM conversation as well as information from all previous study visits, including details of prior SDM discussions, HbA1c goals, current medications, HbA1c levels, and comorbidities.¹

The primary outcomes of interest for the study were the impact of the combined CDS tool/SDM intervention on¹:

• individualized HbA1c goals and/or modifications in the use of insulin or sulfonylureas;
• change in the number of study participants in the group at risk for hypoglycemia before and after the intervention;
• impact of the 2-pronged intervention on non-severe hypoglycemia events.

The researchers employed the Treatment Related Impact Measure—Hypoglycemic Events (TRIM-HYPO) survey to assess the later outcome, according to the study.

The final study cohort numbered 94 participants with a mean age of 74 years (range, 65-93); 57% were women and 95% were White. Among 61% of the cohort, disease duration was 10 years or more; 48% had chronic kidney disease. At baseline, approximately half of participants reported using insulin (51%) and 47% were using a sulfonylurea, the team reported. Of the original 94 participants, 90 completed all 3 study visits.¹

FINDINGS

Boord and colleagues reported that by the final visit at 6 months, 20% of participants had either decreased or eliminated use of insulin or a sulfonylurea. For more than half the cohort (53%), an HbA1c level was obtained before and after establishing a goal for the measure.

For this group of participants, according to the study results, mean HbA1c increased by 0.53% (P <.001) and the number of those assessed as at risk of hypoglycemia decreased by 46% (P <.001). When the investigators evaluated the impact of non-severe hypoglycemic events on daily activities using the TRIM-HYPO scale they found statistically significant reductions for the total score and in each of the scale’s 5 functional domains, including emotional wellbeing, diabetes management, sleep disruption, and work productivity.

“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. Primary care intervention reduces hypoglycemia risk from type 2 diabetes overtreatment in older adults. News release. Endocrine Society. September 27, 2023. Accessed September 30, 2023. https://www.endocrine.org/news-and-advocacy/news-room/2023/primary-care-intervention-reduces-hypoglycemia-risk-in-older-adults