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Effect of De-intensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents

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posted on 27.05.2022, 13:51 authored by Joshua D. Niznik, Xinhua Zhao, Florentina Slieanu, Maria K. Mor, Sherrie L. Aspinall, Walid F. Gellad, Mary Ersek, Ryan P. Hickson, Sydney P. Springer, Loren J. Schleiden, Joseph T. Hanlon, Joshua M. Thorpe, Carolyn T. Thorpe

Objective: Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) and/or limited life expectancy (LLE). We evaluated the effect of de-intensifying diabetes medications on all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control.

Research Design and Methods: We conducted a national retrospective cohort study of 2,082 newly admitted non-hospice Veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.5% and ≥1 diabetes medication) in fiscal years 2009-2015. Diabetes treatment de-intensification (dose decrease or discontinuation of a non-insulin agent or stopping insulin sustained ≥7 days) was identified within 30 days following HbA1c measurement. To adjust for confounding, entropy weights were used to balance covariates between NH residents who de-intensified vs. continued medications. We used the Aalen-Johansen estimator to calculate the 60-day cumulative incidence and risk ratios (RR) for ED or hospital visits and deaths. 

Results: Diabetes medications were de-intensified for 27%. In the subsequent 60 days, 28.5% of all residents were transferred to the ED or acute hospital setting for any cause and 3.9% died. After entropy weighting, de-intensifying was not associated with 60-day all-cause ED visits or hospitalizations (RR = 0.99 [0.84, 1.18]) or 60-day mortality (RR = 1.52 [0.89-2.81]). 

Conclusion: Among NH residents with LLE/AD who may be inappropriately overtreated with tight glycemic control, de-intensification of diabetes medications was not associated with increased risk of 60-day all-cause ED visits, hospitalization, or death in NH residents with LLE/AD.


Funding

This work was supported by the U.S. Department of Veterans Affairs (IIR 14-306 VA HSR&D, principal investigator Carolyn Thorpe). Dr. Niznik is supported by a career development award from the National Institutes on Aging (1K08AG071794). Dr. Hanlon is supported by a VA Health Services Research and Development grant (IIR 18-228). Dr. Hickson was supported as a Postdoctoral Fellow in Advanced Geriatrics with the Geriatric Research, Education, and Clinical Center at the Veterans Affairs Healthcare System, Pittsburgh, PA. Support for VA/CMS data is provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

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