Incidence of non-severe hypoglycaemia and intensity of treatment among veterans with type 2 diabetes in the U.S.A.: a prospective observational study.

AIM: To quantify the incidence of non-severe hypoglycaemic events among veterans with Type 2 diabetes and its association with primary care provider prescribing behaviour. METHODS: This was a prospective observational study involving 30 primary care providers and patients enrolled with these primary care providers, identified from computerized pharmacy records. Two sampling frames were created consisting of (1) patients not treated with insulin and receiving sulfonylurea treatment (with or without other oral hypoglycaemic agents) and (2) patients treated with insulin (with or without sulfonylureas or other oral hypoglycaemic agents). Patients recorded the frequency, proximal cause of, and response to each hypoglycaemic event over a 12-week period and made three visits to a research coordinator over 24 weeks. Data were provided to the primary care provider before their next visit and charts were reviewed for medication changes. RESULTS: A total of 265 patients were enrolled in study. During the 12 weeks of structured self-monitoring of blood glucose, patients recorded a mean (sd) of 6.9 (10.3) hypoglycaemic events. Duration of diabetes increased monotonically with increasing category of hypoglycaemic event (P < 0.001). Among insulin users, an increased frequency of hypoglycaemic events was associated with a decreased likelihood of dose intensification by primary care providers (relative risk 0.86 per event; P = 0.02) but no significant increase in tendency for dose reduction (relative risk 1.04 per event; P = 0.06). Increased frequency of hypoglycaemic events was associated with an increased likelihood of dose reduction (relative risk 1.12 per event; P = 0.03) in the sulfonylurea treatment group. CONCLUSIONS: Non-severe hypoglycaemia is common among veterans with Type 2 diabetes receiving insulin or sulfonylureas and influences the prescribing behaviour of primary care providers.

Diabetic amputations in the VA: are there opportunities for interventions?

Lower limb amputation (LLA) is a devastating complication experienced by some veterans with diabetes. The Veterans Affairs (VA) Healthcare system has identified the prevention of LLA as a priority goal. This study was designed to describe the sources of outpatient care received by veterans with diabetes who have undergone LLA, to determine whether these persons would have been impacted by a VA amputation prevention program. This study was also designed to describe prior amputation history, footwear history, and the pivotal events that led to these amputations. We found that the vast majority of these subjects identified the VA as their primary source of care, and thus would have been available for enrollment in a prevention program. Since over one-half of them had had a prior amputation, diabetics with a prior amputation should be particularly targeted for foot care interventions. Lastly, prescription of protective footwear has the potential to reduce the incidence of shoe-related ulcers and amputations.