Abstract
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. To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. 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. 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. 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. 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.
Highlights
During hospitalization, outpatient medication regimens are frequently modified by inpatient clinicians.[1,2,3] While medication changes are often related to the condition that led to hospitalization, inpatient monitoring may lead to adjustments of medication regimens prescribed for chronic diseases, such as diabetes and hypertension, that are not directly connected to the primary condition for which the patient was hospitalized
In this national retrospective cohort study of older adults with diabetes who were hospitalized for common medical conditions, we found that intensified diabetes medications were prescribed at discharge for 1 in 10 patients, most of whom we estimated were unlikely to benefit from stricter glycemic control
While we found that most patients were unlikely to benefit from intensifications, for patients with both severe inpatient hyperglycemia and uncontrolled outpatient blood glucose levels who may benefit from intensifications, simpler guideline-based insulin regimens, starting with single dose long-acting agents, is likely to lessen hypoglycemia risks compared with more complex short-acting or multidrug insulin regimens.[27]
Summary
Outpatient medication regimens are frequently modified by inpatient clinicians.[1,2,3] While medication changes are often related to the condition that led to hospitalization (eg, receiving antiplatelets following an acute myocardial infarction), inpatient monitoring may lead to adjustments of medication regimens prescribed for chronic diseases, such as diabetes and hypertension, that are not directly connected to the primary condition for which the patient was hospitalized. Intensifications of diabetes medication regimens for patients with previously well-controlled diabetes may contribute to unnecessary polypharmacy and pose a risk of overtreatment. Both overtreatment and medication confusion may risk hypoglycemia,[8] when insulins and sulfonylureas are intensified.[9]
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