VA Choosing Wisely Task Force Helps Elderly Veterans with Diabetes

The U.S. Department of Veterans Affairs’ recently announced the launch of a national Choosing Wisely^® Hypoglycemic Safety Initiative (HSI) to enable veterans and their families, partners and caregivers to create a personal plan for blood sugar management based upon the veterans’ unique health goals. The campaign, which is supported by the Veterans Health Administration (VHA), is the product of a VA Choosing Wisely Task Force that was chartered in 2013 by the Office of the Deputy Under Secretary for Policy and Services.

VA first incorporated shared decision-making about benefits and risks of intensive blood sugar control in its 1997 guidelines and, more recently, in 2010 guidelines. Subsequent government initiatives and medical society recommendations have focused on prescriptions that can contribute to hypoglycemia, or low blood sugar, which can require medical assistance and decrease quality of life, especially in older veterans.

It is estimated that more than half of veterans with diabetes are over 65. Nearly three in 10 veterans in that age group have diabetes, and about 60 percent have other significant illnesses.

“There has been greater recognition about this issue,” said Leonard Pogach, MD, VHA’s National Director, Medicine, and co-chair of the VA Choosing Wisely Task Force. “The government, VA and non-VA research are coming together around this important diabetes safety issue in the United States.”

While other efforts have focused on achieving improved longer term (about three months) glucose control using a test called the A1c and performance measures, Choosing Wisely focuses on fostering conversations between physicians and patients to address their goals and reduce unnecessary and potentially unsafe care.

Inspired by this approach, the VA Choosing Wisely Task Force developed a strategy for glycemic management through the HSI and incorporated Choosing Wisely into an online toolkit, which provides information for veterans and clinicians. The goal is to foster shared, informed decisions among clinicians, veterans and family/caregivers.

Mark McConnell, MD, a VA primary care internist in Upper Michigan, worked with Susan Kirsh, MD, and interested clinical staff in the VA Great Lakes Health Care System to implement the voluntary HSI since 2014. By highlighting government guidelines, Choosing Wisely materials, and the Department of Health and Human Services National Action Plan for Adverse Drug Event Prevention, HSI promotes individualized care to reduce overtreatment across the national VA network.

“Physically, people in the high-risk group can feel terrible due to intensive blood sugar monitoring,” Dr. McConnell said. “They often need to use urgent care or call 911. Psychologically, hypoglycemia can cause a lot of fear and worry. Also, patients and clinicians may worry needlessly about small variation in A1c levels unless they understand the known variation in the test itself.”

HSI encourages all members of the care team, including doctors, nurses, diabetes educators and pharmacists, to take responsibility for identifying high-risk patients. VA also created a simple template in electronic health records (EHR) to remind physicians if a patient is in the high-risk group and to prompt them to discuss individualized glucose control targets.

About 3,800 veterans were initially identified to be among the highest risk patients for overtreatment in Dr. McConnell’s region, based upon advanced age, renal insufficiency or cognitive impairment. Currently, 70 percent of veterans in that group have been evaluated by a clinician or are no longer considered high risk.

“This program is successful because clinicians see these efforts as valid and valuable,” he said. “Choosing Wisely inspired them to choose care with their patients instead of for their patients.”

For the next phase of work focused on glycemic management, Michael Icardi, MD, VA National Director of Pathology and Laboratory Medicine Services, instructed laboratory directors to remove “target values” from A1c laboratory reports and encourage more education about the tests.