Methods
This quality improvement project, conducted at the Fayetteville VA Medical Center (FVAMC), consisted of outpatient services provided at 2 health care centers and 6 community-based outpatient clinics. The project was exempt from institutional review board approval as the protocol met national VA criteria as a quality assurance project.
Patients were identified using the HSI Corporate Data Warehouse (CDR) reports. Once patients were identified, a list was distributed to the appropriate clinical pharmacy specialist (CPS), according to patient aligned care teams (PACTs). The CPS contacted the patient via telephone or in person to conduct hypoglycemia screening. Patients on a sulfonylurea or insulin and an HbA1c < 7% plus 1 risk factor for hypoglycemia (aged ≥ 75 years, serum creatinine[SCr] ≥1.7 mg/dL, diagnosis of cognitive impairment, or prescribed a cholinesterase inhibitor) were included. These risk factors were chosen to align with the future clinical reminder, which is based on an increased risk of hypoglycemia seen in these patient populations.
Patients were included if they were receiving antidiabetic medications through the FVAMC or outside of the VA and/or prescribed by a non-VA provider. Medications and doses prescribed by a non-VA provider were verified with the patient verbally during the initial interview. Once contacted by the CPS, any patients who no longer met inclusion criteria were excluded.
The CPS used a national VA hypoglycemia screening note template to ask the patient about frequency and severity of hypoglycemia. Hypoglycemia was defined as a self-monitored blood glucose < 70 mg/dL with or without symptoms. An additional definition consisted of typical hypoglycemia symptoms as reported by the patient even if self-monitored blood glucose was not obtained while exhibiting symptoms. Using shared decision making between the CPS and veteran, antidiabetic therapy was either relaxed or continued. Relaxing therapy was defined as decreasing doses or discontinuation of antidiabetic medications that are known for potentiating hypoglycemia (ie, sulfonylurea and insulin).
The CPS had autonomy in deciding how much to lower dose(s) or when to discontinue medication(s). Additional counseling in proper medication administration, including appropriate timing of medication administration, also could have been the sole intervention needed for a given patient who experienced hypoglycemia. Counseling would have been considered continuation of therapy. For example, if a patient was experiencing hypoglycemia while taking a sulfonylurea twice daily, the CPS would provide counseling on proper timing of medication administration 20 to 30 minutes before morning and evening meals rather than the patient’s perceived administration of twice daily without regard to meals. Even in patients who met inclusion criteria but who did not experience any hypoglycemia symptoms, the CPS and patient could use shared decision making with emphasis on appropriate HbA1c goals to determine whether relaxation in therapy was appropriate.
Data Collection
Baseline demographics, including prespecified risk factors for hypoglycemia, were collected. Data were imported into the HSI CDW from the national VA hypoglycemia screening note template completed by the CPS. From the data CDW, frequency and severity of hypoglycemia were recorded. The CPS interventions were also quantified; HbA1c data were obtained in patients in whom therapy was relaxed 3- to 6-months postintervention.