3050 — Appropriate Prescribing for Diabetic Patients at High-risk for Hypoglycemia: National Survey of VA Primary Care Providers

Caverly TJ, Ann Arbor VA Center for Clinical Management Resaerch and University of Michigan Medical School; Fagerlin A, Ann Arbor VA Center for Clinical Management Resaerch and University of Michigan Medical School; Zikmund-Fisher BJ, University of Michigan School of Public Health; Kirsh SR, Office of Specialty Care, Veterans Health Administration, Washington, DC; Office of Specialty Care/VA HSR&D QUERI Evaluation Center, Louis Stokes CLE; Kullgren JT, Ann Arbor VA Center for Clinical Management Resaerch and University of Michigan Medical School; Bernstein SJ, University of Michigan Medical School; Klamerus M, Ann Arbor VA Center for Clinical Management Research; Prenevost K, Ann Arbor VA Center for Clinical Management Research; Kerr EA, Ann Arbor VA Center for Clinical Management Resaerch and University of Michigan Medical School;

Objectives:
Nearly one-fifth of older patients with diabetes are put at risk for adverse outcomes by over-aggressive treatment of their diabetes. The VHA has launched a hypoglycemia safety campaign to motivate appropriate de-intensification of medications. To examine whether VHA primary care providers (PCPs) will be receptive to recommendations about de-intensification, we assessed PCP beliefs about reducing diabetes medication in an older patient at high risk for hypoglycemia.

Methods:
We surveyed a national random sample of all non-resident VA PCPs (physicians, nurse practitioners, and physician assistants) with at least one full day of direct patient care. Half of the survey participants were randomized to receive a scenario about a 77-year-old man with long-standing diabetes at high risk for hypoglycemia (creatinine 2.4 mg/dL; hemoglobin A1c 6.5%; on glipizide 10mg BID). Barriers to and facilitators of appropriate de-intensification of diabetes medication were identified using statements answered on a 4-point scale from strongly disagree to strongly agree. The scenario was part of a larger survey assessing acceptability of specific Choosing Wisely recommendations.

Results:
592 providers responded to the hypoglycemia scenario (48% response rate). 39% of providers believed that the patient would benefit if his A1c was maintained below 7% while 45% reported they would not worry about potential harm from tight control. Additionally, 21% of providers reported worrying that the patient would become upset if told to reduce his medications, 42% worried that de-intensification could lead to an A1c that falls outside current performance measures, and 24% worried that it could leave them vulnerable to future malpractice claims. 69% and 85% reported that clinical decision support tools and patient education tools would be helpful in decisions to de-intensify medication, respectively.

Implications:
VA patient safety initiatives to limit overtreatment of diabetes must overcome several challenges, including provider misperceptions about the benefits and harms of tight blood glucose control and concerns about negative repercussions that might follow de-intensification - even when de-intensification represents high-quality care.

Impacts:
We are working with the leaders of the VHA Choosing Wisely Campaign's Hypoglycemia Safety Initiative to incorporate the implications of these results in the roll-out of the campaign.