Cargando…

Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System

IMPORTANCE: Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE: To investigate outcomes associated with intens...

Descripción completa

Detalles Bibliográficos
Autores principales: Anderson, Timothy S., Lee, Alexandra K., Jing, Bocheng, Lee, Sei, Herzig, Shoshana J., Boscardin, W. John, Fung, Kathy, Rizzo, Anael, Steinman, Michael A.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8531994/
https://www.ncbi.nlm.nih.gov/pubmed/34673963
http://dx.doi.org/10.1001/jamanetworkopen.2021.28998
_version_ 1784586983331332096
author Anderson, Timothy S.
Lee, Alexandra K.
Jing, Bocheng
Lee, Sei
Herzig, Shoshana J.
Boscardin, W. John
Fung, Kathy
Rizzo, Anael
Steinman, Michael A.
author_facet Anderson, Timothy S.
Lee, Alexandra K.
Jing, Bocheng
Lee, Sei
Herzig, Shoshana J.
Boscardin, W. John
Fung, Kathy
Rizzo, Anael
Steinman, Michael A.
author_sort Anderson, Timothy S.
collection PubMed
description IMPORTANCE: Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE: To investigate outcomes associated with intensification of outpatient diabetes medications at discharge. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021. EXPOSURE: Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications. MAIN OUTCOMES AND MEASURES: Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A(1c) (HbA(1c)) level, and persistent use of intensified medications at 1 year after discharge. RESULTS: The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA(1c) level was found among those who did vs did not receive intensifications (mean postdischarge HbA(1c), 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, −0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled. CONCLUSIONS AND RELEVANCE: In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA(1c) control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.
format Online
Article
Text
id pubmed-8531994
institution National Center for Biotechnology Information
language English
publishDate 2021
publisher American Medical Association
record_format MEDLINE/PubMed
spelling pubmed-85319942021-11-04 Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System Anderson, Timothy S. Lee, Alexandra K. Jing, Bocheng Lee, Sei Herzig, Shoshana J. Boscardin, W. John Fung, Kathy Rizzo, Anael Steinman, Michael A. JAMA Netw Open Original Investigation IMPORTANCE: Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE: To investigate outcomes associated with intensification of outpatient diabetes medications at discharge. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021. EXPOSURE: Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications. MAIN OUTCOMES AND MEASURES: Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A(1c) (HbA(1c)) level, and persistent use of intensified medications at 1 year after discharge. RESULTS: The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA(1c) level was found among those who did vs did not receive intensifications (mean postdischarge HbA(1c), 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, −0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled. CONCLUSIONS AND RELEVANCE: In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA(1c) control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management. American Medical Association 2021-10-21 /pmc/articles/PMC8531994/ /pubmed/34673963 http://dx.doi.org/10.1001/jamanetworkopen.2021.28998 Text en Copyright 2021 Anderson TS et al. JAMA Network Open. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the CC-BY License.
spellingShingle Original Investigation
Anderson, Timothy S.
Lee, Alexandra K.
Jing, Bocheng
Lee, Sei
Herzig, Shoshana J.
Boscardin, W. John
Fung, Kathy
Rizzo, Anael
Steinman, Michael A.
Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System
title Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System
title_full Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System
title_fullStr Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System
title_full_unstemmed Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System
title_short Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System
title_sort intensification of diabetes medications at hospital discharge and clinical outcomes in older adults in the veterans administration health system
topic Original Investigation
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8531994/
https://www.ncbi.nlm.nih.gov/pubmed/34673963
http://dx.doi.org/10.1001/jamanetworkopen.2021.28998
work_keys_str_mv AT andersontimothys intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT leealexandrak intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT jingbocheng intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT leesei intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT herzigshoshanaj intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT boscardinwjohn intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT fungkathy intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT rizzoanael intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem
AT steinmanmichaela intensificationofdiabetesmedicationsathospitaldischargeandclinicaloutcomesinolderadultsintheveteransadministrationhealthsystem