Glycemic Over- and Undertreatment in VA Nursing Home Residents with Type 2 Diabetes: a Retrospective Cohort Study
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Division of Hospital Medicine, San Francisco VA Medical Center , San Francisco , CA , USA; 2Division of Geriatrics, University of California, San Francisco , San Francisco , CA , USA; 3Department of Physiological Nursing, UCSF , San Francisco , CA , USA; 4Geriatrics and Extended Care Service, San Francisco VA Medical Center , San Francisco , CA , USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05479-5 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019
INTRODUCTION
For nursing home (NH) residents, clinical guidelines recommend less stringent hemoglobin A1c (HbA1c) targets between 7.5 and 9.0%1–3 while avoiding medications with higher hypoglycemia risks such as insulin. Previous studies in community-dwelling older adults have suggested that overly intensive glycemic treatment may be common.4, 5 However, little is known about current glycemic treatment practices among NH residents with type 2 diabetes mellitus (T2DM). Our objective was to determine the rates of glycemic overtreatment (defined as insulin use with HbA1c < 6.5%) and glycemic undertreatment (defined as no glucose-lowering medications with HbA1c ≥ 8.5%) in older adults recently admitted to the NH.
METHODS
We conducted a retrospective cohort study of Veterans Affairs (VA) nursing home residents over age 65 with T2DM from January 1, 2013, to December 31, 2015. We defined diabetes as HbA1c > 6.5% or use of glucose-lowering medication (GLM) in the year prior to NH admission. Residents with ICD codes for type 1 diabetes, length of stay (LOS) < 30 days, hospice stays, or with no HbA1c measurement during NH stay were excluded. We identified the date of the first HbA1c during NH stay (index HbA1c date) and categorized NH residents into five mutually exclusive categories based on glucose-lowering medication (GLM) use on the index HbA1c date: (1) no glucose-lowering medications, (2) metformin use without use of any other GLMs, (3) use of other oral GLMs in any combination (but without insulin use), (4) any short-acting Received August 7, 2019 Accepted October 2, 2019
insulin use (in combination with oral GLMs or alone, but without use of long-acting insulin), (5) any long-acting insulin use. We defined likely overtreatment as HbA1c < 6.5 with any insulin use, and likely undertreatment as HbA1c ≥ 8.5 with no GLM use. This study was reviewed and approved by the University of California, San Francisco Committee on Human Research.
RESULTS
We identified 5471 VA NH residents who met inclusion and exclusion criteria. Mean age was 74.5, all were male, and 54% had NH LOS > 90 days. Our cohort had a high comorbidity burden (mean Charlson Comorbidity Index of 6) and most were dependent on several activities of daily living (Table 1). The index HbA1c was within the first 30 days of NH admission in 62% of residents. Seven percent were on metformin alone, 9% were on oral GLMs without insulin, 12% were on short-acting insulin without long-acting insulin use, and 4
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