Koehn Deborah A, Dungan Kathleen Marie, Wallia Amisha, Lucas Deborah Otcasek, Lash Robert W, Becker Mila N, Dardick Lawrence D, Boord Jeffrey B
VCU Stony Point Women's Health, Richmond, Virginia, USA.
Division of Endocrinology, Diabetes & Metabolism, The Ohio State University, Columbus, Ohio, USA.
J Am Geriatr Soc. 2023 Dec;71(12):3701-3710. doi: 10.1111/jgs.18566. Epub 2023 Sep 21.
Hypoglycemia from overtreatment is a serious but underrecognized complication among older adults with type 2 diabetes. However, diabetes treatment is seldom deintensified. We assessed the effectiveness of a Clinical Decision Support (CDS) tool and shared decision-making (SDM) in decreasing the number of patients at risk for hypoglycemia and reducing the impact of non-severe hypoglycemic events.
HypoPrevent was a pre-post, single arm study at a five-site primary care practice. We identified at-risk patients (≥65 years-old, with type 2 diabetes, treated with insulin or sulfonylureas, and HbA < 7.0%). During three clinic visits over 6 months, clinicians used the CDS tool and SDM to assess hypoglycemic risk, set individualized HbA goals, and adjust use of hypoglycemic agents. We assessed the number of patients setting individualized HbA goals or modifying medication use, changes in the population at risk for hypoglycemia, and changes in impact of non-severe hypoglycemic events using a validated patient-reported outcome tool (TRIM-HYPO).
We enrolled 94 patients (mean age-74; mean HbA (±SD)-6.36% ± 0.43), of whom 94% set an individualized HbA goal at either the baseline or first follow-up visit. Ninety patients completed the study. Insulin or sulfonylurea use was decreased or eliminated in 20%. An HbA level before and after goal setting was obtained in 53% (N = 50). Among these patients, the mean HbA increased 0.53% (p < 0.0001) and the number of patients at-risk decreased by 46% (p < 0.0001). Statistically significant reductions in the impact of hypoglycemia during daily activities occurred in both the total score and each functional domain of TRIM-HYPO.
In a population of older patients at risk for hypoglycemia, the use of a CDS tool and SDM reduced the population at risk and decreased the use of insulin and sulfonylureas. Using a patient-reported outcome tool, we demonstrated significant reductions in the impact of hypoglycemia on daily life.
过度治疗引起的低血糖是老年2型糖尿病患者中一种严重但未得到充分认识的并发症。然而，糖尿病治疗很少会减弱强度。我们评估了临床决策支持（CDS）工具和共同决策（SDM）在减少低血糖风险患者数量以及降低非严重低血糖事件影响方面的有效性。
HypoPrevent是一项在五个初级保健机构进行的前后单臂研究。我们确定了有风险的患者（年龄≥65岁，患有2型糖尿病，接受胰岛素或磺脲类药物治疗，且糖化血红蛋白<7.0%）。在6个月内的三次门诊就诊期间，临床医生使用CDS工具和SDM来评估低血糖风险、设定个体化糖化血红蛋白目标并调整降糖药物的使用。我们使用经过验证的患者报告结局工具（TRIM-HYPO）评估设定个体化糖化血红蛋白目标或调整药物使用的患者数量、低血糖风险人群的变化以及非严重低血糖事件影响的变化。
我们纳入了94例患者（平均年龄74岁；平均糖化血红蛋白（±标准差）6.36%±0.43），其中94%在基线或首次随访就诊时设定了个体化糖化血红蛋白目标。90例患者完成了研究。20%的患者减少或停用了胰岛素或磺脲类药物。53%（N = 50）的患者获得了目标设定前后的糖化血红蛋白水平。在这些患者中，平均糖化血红蛋白升高了0.53%（p < 0.0001），有风险的患者数量减少了46%（p < 0.0001）。TRIM-HYPO的总分及每个功能领域在日常活动中低血糖影响方面均有统计学显著降低。
在有低血糖风险的老年患者群体中，使用CDS工具和SDM减少了有风险的人群数量，并减少了胰岛素和磺脲类药物的使用。通过患者报告结局工具，我们证明了低血糖对日常生活的影响有显著降低。
