Some Clinicians Worry More About Malpractice Than Hypoglycemia

By Brenda L. Mooney


Eve Kerr, MD, MPH

ANN ARBOR, MI — Despite a VA campaign to raise awareness of hypoglycemia and recommendations from the national Choosing Wisely campaign to less aggressively treat older patients with limited life expectancy, almost half of the VA primary care providers responding to a survey said they would not be concerned about the harms of tight glycemic control for a hypothetical 77-year-old man with diabetes.

In fact, nearly one-quarter of the respondents said they were more worried that de-intensifying medication for the man in the hypothetical situation — with a hemoglobin A1c (HbA1c) of 6.5%, high risk for hypoglycemia, severe kidney disease and prescribed glipizide 10 mg, twice daily — could leave them vulnerable to future malpractice claims.1

That could help explain the results of a related study, also published online by JAMA Internal Medicine, which found that too many older patients with very low HbA1c or blood pressure levels continue to be overtreated in the VHA.2

Study authors decried the missing opportunity to de-intensify treatment.


a) The following scenario was presented in the survey. “Imagine that you are seeing a 77-year-old male patient with long-standing type 2 diabetes, chronic kidney disease, chronic low back pain, and well-controlled hypertension who presents for a routine follow-up visit. He has no new complaints and is looking forward to a planned visit by his daughter and grandchildren. The patient has recent laboratory results that show a stable creatinine level of 2.4mg/dL (estimated glomerular filtration rate, 26 mL/min) and an HbA1c of 6.5% (HbA1c 6 months ago was 6.7%). He is receiving the following medications: lisinopril, 20mg/d; hydrochlorothiazide, 25mg/d; glipizide, 10mg, twice daily; acetaminophen, 325mg, as needed; and simvastatin, 20mg/d. To what extent do you disagree or agree with the following statements about the patient’s diabetes treatment?” The original items contained 4 response choices, all of which were dichotomized for analyses to improve the distribution of responses and simplify the presentation of these results. To convert creatinine to micromoles per liter, multiply by 88.4; HbA1c to a proportion of total hemoglobin, multiply by 0.01. b) Numbers vary for each item due to item nonresponse. c) These scenario questions were associated with a perception that it would be difficult to follow the ChoosingWisely recommendation to avoid using medications to achieve tight blood glucose control (HbA1c <7.5%).

In fact, only 27% or fewer of older patients treated at the VHA had their medications reduced, despite very low HbA1c or blood pressure levels, according to researchers from the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor, MI.

“As physicians, we want to make sure patients get the care they need, but we should also avoid care that might harm them,” said Eve Kerr, MD, MPH, an author on both studies and director of the VA Center for Clinical Management Research. “If something is not likely to benefit them but is likely to cause other problems, then we should pull back. We were surprised to find that this is not yet happening despite guidelines to aid providers in determining who qualifies for de-intensification.”

Background information in the report notes that new guidelines and the Choosing Wisely campaign recommend less-aggressive treatment for older patients and those with limited life expectancy, such as a target HbA1c level of 7.5% or 8%, while another report recommends that older patients seek to achieve a systolic blood pressure (SBP) of 150 mm Hg and no longer try to reach a level below 140 mm Hg.

“Every guideline for physicians has detailed guidance for prescribing and stepping up or adding drugs to control these risk factors, and somewhere toward the end it says ‘personalize treatment for older people,’” explained lead author Jeremy B. Sussman, MD, MS. “But nowhere do they say actually stop medication in the oldest patients to avoid hypoglycemia or too-low blood pressure.”

The VHA study looked at data from 2012 and included 211,667 patients older than 70 receiving blood pressure-lowering medications — other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers — or glucose-lowering medications other than metformin hydrochloride.

More than half of the 211,667 participants actively treated for blood pressure had moderately low BP — SBP of 120 to 129 mm Hg or diastolic blood pressure [DBP] less than 65 mm Hg — or very low BP — less than 120 mm Hg or DBP less than 65 mm Hg.

Treatment was de-intensified in 16% of the 25,955 patients with moderately low blood pressure levels and in 18.8% of the 81,226 patients with very low blood pressure levels.

For the 179,991 patients in the actively treated HbA1c group, medication was reduced in 20.9% of the 23,769 patients with moderately low HbA1c — 6.0% to 6.4% — levels and in 27% of the 12,917 patients with very low HbA1c — less than 6.0%.

Results indicate that, of patients with very low BP levels whose treatment was not de-intensified, only 0.2% had a follow-up BP measurement that was elevated. Of patients with very low HbA1c levels whose treatment was not de-intensified, meanwhile, less than 0.8% had a follow-up HbA1c measurement that was 7.5% or greater.

“Future performance management systems should consider how to create incentives against both overuse and underuse to motivate appropriate treatment, including de-intensification of treatment that is personalized to individual needs, risks and benefits,” according to the researchers. “In addition, healthcare professionals should assess the harms of intensive therapy just as they do the benefits. These changes may require new clinical decision support tools, new performance measures and, most important, a new perspective focusing on personalized, appropriate care.”

Study authors emphasized that a patient who has been on medication for diabetes or blood pressure for many years and is now in their late 70s or older might already have accrued the vast majority of benefits from keeping their levels under control. As the chance of a dangerous glycemic or blood pressure dip increases with age, however, the short-term risk starts to balance out any long-term gain.

“Physicians are used to thinking about when to start medications, and, if a patient isn’t complaining and appears to be doing fine, stopping medications may not be first thing on their mind,” noted Tanner Caverly, MD, MPH, who led the survey of primary care providers. “As we get more precise evidence about the degree of benefit and harm from using these medications, it’s showing us that we need to dial back in some patients.”

That survey, conducted in late 2014, was returned by 594 primary care providers, a 48.6% response rate. Most of the participants were physicians, 68,8%, followed by nurse practitioners, 23.4%, and physician assistants, 7.8%.

Earlier this year, the VA announced the Hypoglycemic Safety Initiative (HSI) to encourage veterans with diabetes to seek support to lower the risk of hypoglycemia.

“The Hypoglycemic Safety Initiative is designed to enable veterans and their families, partners and caregivers to create a personal plan for blood sugar management based upon the veteran’s unique health goals,” said Carolyn Clancy, MD, then the interim under secretary for health and now the VHA’s Chief Medical Officer. “Our objective is to change how diabetes is managed in VA and the United States and to help patients improve their personal well-being, not just manage their numbers.”

Clancy added that hypoglycemia “has only recently been prioritized as a national public health issue, but federal agencies are taking a leadership role in addressing the problem.”

1 Caverly TJ, Fagerlin A, Zikmund-Fisher BJ, Kirsh S, Kullgren JT, Prenovost K, Kerr EA. Appropriate Prescribing for Patients With Diabetes at High Risk for Hypoglycemia: National Survey of Veterans Affairs Health Care Professionals. JAMA Intern Med. 2015 Oct 26:1-3. doi: 10.1001/jamainternmed.2015.5950. [Epub ahead of print] PubMed PMID: 26502113.

2 Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, Vijan S, Hofer TP. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus. JAMA Intern Med. 2015 Oct 26:1-8. doi: 10.1001/jamainternmed.2015.5110. [Epub ahead of print] PubMed PMID: 26502220.