Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals | Clinical Pharmacy and Pharmacology | JAMA Network Open | JAMA Network
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    Original Investigation
    Geriatrics
    March 24, 2020

    Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

    Author Affiliations
    • 1Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 2San Francisco VA Medical Center, San Francisco, California
    • 3Division of Geriatrics, University of California, San Francisco
    JAMA Netw Open. 2020;3(3):e201511. doi:10.1001/jamanetworkopen.2020.1511
    Key Points español 中文 (chinese)

    Question  How often are older adults discharged with changes to their outpatient diabetes medication regimens following hospitalization for common medical conditions?

    Findings  In this cohort study of 16 178 older adults hospitalized in the Veterans Health Administration national health system, 1 in 10 patients was discharged with intensified diabetes medications. Nearly half of patients receiving intensifications had already reached outpatient blood glucose goals or had limited life expectancy.

    Meaning  During hospitalization, consideration of long-term diabetes control is needed in addition to inpatient blood glucose recordings to reduce potentially nonbeneficial medication changes when older adults are discharged home.

    Abstract

    Importance  Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home.

    Objective  To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications.

    Design, Setting, and Participants  This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013.

    Main Outcomes and Measures  Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics.

    Results  Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels.

    Conclusions and Relevance  In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.

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