Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
San Francisco VA Medical Center, San Francisco, California.
JAMA Netw Open. 2020 Mar 2;3(3):e201511. doi: 10.1001/jamanetworkopen.2020.1511.
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.
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.
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.
住院老年患者常出现血糖升高，这可能导致临床医生在出院时加强门诊糖尿病药物治疗，从而使患者返回家中时面临过度治疗的潜在风险。
评估住院老年患者出院时接受强化糖尿病药物治疗的频率，以及这些强化治疗相关的获益可能性。
设计、设置和参与者：本回顾性队列研究纳入了年龄在 65 岁及以上、既往无需胰岛素治疗的糖尿病患者。该研究纳入了 2011 年至 2013 年期间在退伍军人事务部医院因常见医疗状况住院的患者。
门诊糖尿病药物的强化，定义为出院时接受新的或更高剂量的药物治疗，而入院前正在服用的药物剂量低于此。采用混合效应逻辑回归模型来控制患者和住院特征。
在 16178 例患者中（平均[标准差]年龄为 73[8]岁；15895[98%]为男性），8535 例（53%）患者入院前糖化血红蛋白（HbA1c）水平<7.0%，1044 例（6%）患者 HbA1c 水平>9.0%。总体而言，1626 例患者（10%）出院时接受了强化糖尿病药物治疗，其中 781 例（5%）使用了新的胰岛素，557 例（3%）使用了强化磺脲类药物。由于预期寿命有限或已达到 HbA1c 目标，近一半接受强化治疗的患者（49%[791/1626]）不太可能获益，而 20%（329/1626）有获益的可能。入院前 HbA1c 水平和住院期间的血糖记录均与出院时接受强化糖尿病药物治疗相关。在入院前 HbA1c 水平<7.0%的患者中，无高住院血糖水平的患者接受强化治疗的预测概率为 4%（95%CI，3%-4%），而高住院血糖水平的患者为 21%（95%CI，15%-26%）。
在这项研究中，因常见医疗状况住院的 10 例老年糖尿病患者中有 1 例接受了强化糖尿病药物治疗。由于预期寿命有限或已达到 HbA1c 目标，近一半的患者不太可能从中获益。
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