Qualitative analysis of reasons for hospitalization for severe hypoglycemia among older adults with diabetes

Weronika E Pasciak, David N Berg, Emily Cherlin, Terri Fried, Kasia J Lipska, Weronika E Pasciak, David N Berg, Emily Cherlin, Terri Fried, Kasia J Lipska

Abstract

Background: Hospital admissions for severe hypoglycemia are associated with significant healthcare costs, decreased quality of life, and increased morbidity and mortality, especially for older adults with diabetes. Understanding the reasons for hypoglycemia hospitalization is essential for the development of effective interventions; yet, the causes and precipitants of hypoglycemia are not well understood.

Methods: We conducted a qualitative study of non-nursing home patients aged 65 years or older without cognitive dysfunction admitted to a single tertiary-referral hospital with diabetes-related hypoglycemia. During the hospitalization, we conducted one-on-one, in-depth, semi-structured interviews to explore: (1) experiences with diabetes management among patients hospitalized for severe hypoglycemia; and (2) factors contributing and leading to the hypoglycemic event. Major themes and sub-themes were extracted using the constant comparative method by 3 study authors.

Results: Among the 17 participants interviewed, the mean age was 78.9 years of age, 76.5% were female, 64.7% African American, 64.7% on insulin, and patients had an average of 13 chronic conditions. Patients reported: (1) surprise at hypoglycemia despite living with diabetes for many years; (2) adequate support, knowledge, and preparedness for hypoglycemia; (3) challenges balancing a diet that minimizes hyperglycemia and prevents hypoglycemia; (4) the belief that hyperglycemia necessitates medical intervention, but hypoglycemia does not; and (5) tension between clinician-prescribed treatment plans and self-management based on patients' experience. Notably, participants did not report the previously cited reasons for hypoglycemia, such as food insecurity, lack of support or knowledge, or treatment errors.

Conclusions: Our findings suggest that some hypoglycemic events may not be preventable, but in order to reduce the risk of hypoglycemia in older individuals at risk: (1) healthcare systems need to shift from their general emphasis on the avoidance of hyperglycemia towards the prevention of hypoglycemia; and (2) clinicians and patients need to work together to design treatment regimens that fit within patient capacity and are flexible enough to accommodate life's demands.

Keywords: Hospitalization for hypoglycemia; Older adults with diabetes; Qualitative study.

Conflict of interest statement

K.L. receives support from the Centers for Medicare & Medicaid Services (CMS) to develop and evaluate publicly reported outcomes measures. Other authors report no competing interests.

References

    1. U.S. Department for Health and Human Services . National Action Plan for Adverse Drug Event Prevention. 2014.
    1. Centers for Disease Control and Prevention. National Diabetes Statistics Report . 2020, Estimates of diabetes and its Burden in the United States. 2020.
    1. Geller AI, Shehab N, Lovegrove MC, Kegler SR, Weidenbach KN, Ryan GJ, Budnitz DS. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174(5):678–686. doi: 10.1001/jamainternmed.2014.136.
    1. Iqbal A, Heller SR. The role of structured education in the management of hypoglycaemia. Diabetologia. 2018;61(4):751–760. doi: 10.1007/s00125-017-4334-z.
    1. Karter AJ, Moffet HH, Liu JY, Lipska KJ. Surveillance of hypoglycemia—limitations of emergency department and hospital utilization data. JAMA Intern Med. 2018;178(7):987–988. doi: 10.1001/jamainternmed.2018.1014.
    1. Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, Heller SR, Rodriguez H, Rosenzweig J, Vigersky R. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care. 2013;36(5):1384–1395. doi: 10.2337/dc12-2480.
    1. Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, Woodward M, Ninomiya T, Neal B, MacMahon S, Grobbee DE, Kengne AP, Marre M, Heller S. Severe hypoglycemia and risks of vascular events and death. N Engl J Med. 2010;363(15):1410–1418. doi: 10.1056/NEJMoa1003795.
    1. McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers SA. Increased mortality of patients with diabetes reporting severe hypoglycemia. Diabetes Care. 2012;35(9):1897–1901. doi: 10.2337/dc11-2054.
    1. Bonds DE, Miller ME, Dudl J, Feinglos M, Ismail-Beigi F, Malozowski S, Seaquist E, Simmons DL, Sood A. Severe hypoglycemia symptoms, antecedent behaviors, immediate consequences and association with glycemia medication usage: secondary analysis of the ACCORD clinical trial data. BMC Endocr Disord. 2012;12(1):5. doi: 10.1186/1472-6823-12-5.
    1. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–2012. doi: 10.1056/NEJMsa1103053.
    1. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US emergency department visits for outpatient adverse drug events, 2013-2014. JAMA. 2016;316(20):2115–2125. doi: 10.1001/jama.2016.16201.
    1. Whitmer RA, Karter AJ, Yaffe K. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA. 2009;301(15):1565–1572. doi: 10.1001/jama.2009.460.
    1. Johnston SS, Conner C, Aagren M. Association between hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes. Diabetes Obes Metab. 2012;14(7):634–643. doi: 10.1111/j.1463-1326.2012.01583.x.
    1. Laiteerapong N, Karter AJ, Liu JY, Moffet HH, Sudore R, Schillinger D, John PM, Huang ES. Correlates of quality of life in older adults with diabetes: the diabetes & aging study. Diabetes Care. 2011;34(8):1749–1753. doi: 10.2337/dc10-2424.
    1. Silbert R, Salcido-Montenegro A, Rodriguez-Gutierrez R, Katabi A, McCoy RG. Hypoglycemia among patients with type 2 diabetes: epidemiology, risk factors, and prevention strategies. Curr Diab Rep. 2018;18(8):53. doi: 10.1007/s11892-018-1018-0.
    1. Seligman HK, Jacobs EA, Lopez A, Sarkar U, Tschann J, Fernandez A. Food insecurity and hypoglycemia among safety net patients with diabetes. Arch Intern Med. 2011;171(13):1204–1206. doi: 10.1001/archinternmed.2011.287.
    1. Waitman J, Caeiro G, Romero Gonzalez SA, Ré DP, Daghero A, Gonzalez CD, Umpierrez GE. Social vulnerability and hypoglycemia among patients with diabetes. Endocrinol Diabetes Nutr. 2017;64(2):92–99. doi: 10.1016/j.endinu.2016.11.008.
    1. Seligman HK, Davis TC, Schillinger D, Wolf MS. Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes. J Health Care Poor Underserved. 2010;21(4):1227–1233. doi: 10.1353/hpu.2010.0921.
    1. Seligman HK, Bolger AF, Guzman D, López A, Bibbins-Domingo K. Exhaustion of food budgets at Month’s end and hospital admissions for hypoglycemia. Health Aff. 2014;33(1):116–123. doi: 10.1377/hlthaff.2013.0096.
    1. Basu S, Berkowitz SA, Seligman H. The monthly cycle of hypoglycemia: an observational claims-based study of emergency room visits, hospital admissions, and costs in a commercially insured population. Med Care. 2017;55(7):639–645. doi: 10.1097/MLR.0000000000000728.
    1. Berkowitz SA, Aragon K, Hines J, Seligman H, Lee S, Sarkar U. Do clinical standards for diabetes care address excess risk for hypoglycemia in vulnerable patients?A Systematic Review Health. Serv Res. 2013;48(4):1299–1310. doi: 10.1111/1475-6773.12048.
    1. Endocrine Society . Hypoglycemia quality collaborative strategic blueprint: a resource to increase awareness of hypoglycemia and promote activities to reduce its incidence. 2016.
    1. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009;119(10):1442–1452. doi: 10.1161/CIRCULATIONAHA.107.742775.
    1. Crabtree BF, Miller WL. Doing Qualitative Research. 2nd ed. Thousand Oaks: Sage Publications; 1999.
    1. Michael Quinn Patton. Qualitative Research & Evaluation Methods. 3rd ed. Thousand Oaks: Sage Publications; 2002.
    1. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine Publishing Company; 1967.
    1. Rodriguez-Gutierrez R, Lipska KJ, McCoy RG, Ospina NS, Ting HH, Montori VM. Hypoglycemia as an indicator of good diabetes care. BMJ. 2016;352. 10.1136/bmj.i1084.
    1. Rodriguez-Gutierrez R, Ospina NS, McCoy RG, et al. Inclusion of hypoglycemia in clinical practice guidelines and performance measures in the Care of Patients with Diabetes. JAMA Intern Med. 2016;176(11):1714–1716. doi: 10.1001/jamainternmed.2016.5046.
    1. Ahola AJ, Groop P-H. Barriers to self-management of diabetes. Diabet Med. 2013;30(4):413–420. doi: 10.1111/dme.12105.
    1. Sircar M, Bhatia A, Munshi M. Review of hypoglycemia in the older adult: clinical implications and management. Can J Diabetes. 2016;40(1):66–72. doi: 10.1016/j.jcjd.2015.10.004.
    1. American Diabetes Association 11. Older Adults: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2018;41(Supplement 1):S119–S125. doi: 10.2337/dc18-S011.
    1. Walker G, Chen J, Sainsbury C, Jones G. Structured education using dose adjustment for Normal eating (DAFNE) reduces long-term HbA1c and HbA1c variability. Diabet Med. 2018;35(6):745–749. doi: 10.1111/dme.13621.
    1. Murphy K, Casey D, Dinneen S, Lawton J, Brown F. Participants’ perceptions of the factors that influence diabetes self-management following a structured education (DAFNE) programme. J Clin Nurs. 2011;20(9–10):1282–1292. doi: 10.1111/j.1365-2702.2010.03564.x.
    1. Group BMJP Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ. 2002;325(7367):746. doi: 10.1136/bmj.325.7367.746.
    1. Hopkins D, Lawrence I, Mansell P, Thompson G, Amiel S, Campbell M, Heller S. Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the U.K. DAFNE experience. Diabetes Care. 2012;35(8):1638–1642. doi: 10.2337/dc11-1579.
    1. de Zoysa N, Rogers H, Stadler M, Gianfrancesco C, Beveridge S, Britneff E, Choudhary P, Elliott J, Heller S, Amiel SA. A psychoeducational program to restore hypoglycemia awareness: the DAFNE-HART pilot study. Diabetes Care. 2014;37(3):863–866. doi: 10.2337/dc13-1245.
    1. Fried TR, Tinetti ME, Iannone L. Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011;171(1):75–80. doi: 10.1001/archinternmed.2010.318.
    1. Ross J, Stevenson FA, Dack C, et al. Health care professionals’ views towards self-management and self-management education for people with type 2 diabetes. BMJ Open. 2019;9(7). 10.1136/bmjopen-2019-029961.
    1. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50(6):813–828. doi: 10.1016/S0277-9536(99)00338-X.
    1. Peek ME, Odoms-Young A, Quinn MT, Gorawara-Bhat R, Wilson SC, Chin MH. Race and shared decision-making: perspectives of African-Americans with diabetes. Soc Sci Med. 2010;71(1):1–9. doi: 10.1016/j.socscimed.2010.03.014.

Source: PubMed

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