Trends in Prevalence, Incidence and Pharmacologic Management of Diabetes Mellitus Among Seniors Newly Admitted to Long-Term Care Facilities in Saskatchewan between 2003 and 2011

doi:10.1016/j.jcjd.2014.10.002

Canadian Journal of Diabetes

Volume 39, Issue 2, April 2015, Pages 138-145

https://doi.org/10.1016/j.jcjd.2014.10.002 Get rights and content

Abstract

Objective

We aimed to describe trends in the prevalence and incidence of diabetes mellitus and also report the overall use of diabetes medications among patients newly admitted to a long-term care facility (LTCF).

Methods

A retrospective cohort study was done using health administrative databases in Saskatchewan. Eligible patients were newly admitted to LTCF in Saskatchewan between 2003 and 2011 and maintained LTCF residency for at least 6 months. Prevalence of diabetes was defined with physician or hospital claims in the 2 years preceding admission. Antihyperglycemic medication use was estimated from prescription claims data during the first 6 months after LTCF admission. All data were descriptively analyzed.

Results

The validated case definition for diabetes (≥2 diagnostic claims) in the 2 years before or 6 months after admission was met by 16.9% of patients (2471 of 14,624). An additional 965 patients (6.6%) had a single diabetes diagnostic claim or antihyperglycemic prescriptions only. Among patients receiving antihyperglycemic therapies, 64.9% (1518 of 2338) were exclusively managed with oral medications, and metformin was the most commonly used medication. Glyburide was commonly withdrawn after LTCF admission. Insulin use was observed in 23.9% of diabetes patients, with a mean daily average consumption of 54.7 units per day.

Conclusions

Use of diabetes medications appear to generally align with Canadian practice recommendations as evidenced by declining use of glyburide and frequent use of metformin. Future studies should examine clinical benefits and safety of hypoglycemic agent use in LTCFs.

Résumé

Objectif

Notre but était de décrire les tendances de la prévalence et de l’incidence du diabète sucré, puis de rapporter l’utilisation globale des médicaments contre le diabète chez les patients récemment admis dans un établissement de soins de longue durée (ÉSLD).

Méthodes

Une étude de cohorte rétrospective était réalisée à l’aide des banques de données administratives sur la santé en Saskatchewan. Les patients admissibles avaient récemment été admis à l’ÉSLD en Saskatchewan entre 2003 et 2011 et avaient séjourné à l’ÉSLD au moins 6 mois. La prévalence du diabète était définie par le médecin ou la facturation des services hospitaliers dans les 2 années précédant l’admission. L’utilisation de médicaments antihyperglycémiques était estimée d’après les données de réclamations de médicaments sur ordonnance durant les 6 premiers mois suivant l’admission à l’ÉSLD. Toutes les données étaient analysées de manière descriptive.

Résultats

La validation de la définition de cas du diabète (≥ 2 réclamations liées au diagnostic) 2 ans avant ou 6 mois après l’admission était atteinte par 16,9 % des patients (2471 sur 14 624). Neuf cent soixante-cinq (965) patients additionnels (6,6 %) avaient seulement une réclamation liée au diagnostic du diabète ou aux ordonnances de médicaments antihyperglycémiques. Chez les patients recevant des thérapies antihyperglycémiques, 64,9 % (1518 sur 2338) étaient exclusivement traités par des médicaments oraux dont la metformine était le médicament le plus communément utilisé. Le glyburide était généralement interrompu après l’admission à l’ÉSLD. L’utilisation de l’insuline à raison d’une consommation moyenne quotidienne de 54,7 unités était observée chez 23,9 % des patients diabétiques.

Conclusions

L’utilisation de médicaments contre le diabète semble généralement s’aligner sur les recommandations canadiennes de la pratique comme le confirment l’utilisation décroissante du glyburide et l’utilisation fréquente de la metformine. Des études subséquentes devraient examiner les avantages cliniques et l’innocuité de l’utilisation des agents hypoglycémiques dans les ÉSLD.

Introduction

The prevalence of diabetes mellitus has increased substantially over the past 2 decades, and elderly patients are most commonly affected. Nearly 1 in every 3 Canadians (23% to 29%) aged 75 to 79 years has been diagnosed with diabetes, and many more may have impaired glucose tolerance or undiagnosed disease (1). The 2013 Canadian Diabetes Association (CDA) guidelines advocate for an individualized approach to diabetes management among elderly patients (2). Diabetes medications can cause hypoglycemia, especially among frail elderly patients residing in long-term care facilities (LTCF); thus, management of many elderly patients requires lower treatment intensity to ensure patient safety. Also, medications such as glyburide 3, 4, 5 and insulin have been associated with a substantially increased risk for hypoglycemia 6, 7. Both of these medications should be used cautiously for elderly patients residing in LTCF because the level of frailty observed in these institutions is typically high.

Despite the rising prevalence and high risks for adverse events among frail elderly, the literature describing diabetes epidemiology and management among residents of Canadian LTCFs is limited. In the province of Saskatchewan, diabetes prevalence was found to range from 21% to 25%, depending on the data source (8). A lower prevalence of 17% was reported in a survey of 5 LTCFs in the province of British Columbia (9). Although it is expected that the prevalence of diabetes among LTCF patients is increasing corresponding to community-based estimates, time trends of diabetes in Canadian LTCFs have not been examined previously.

A systematic review of 20 studies with a total sample of 779 707 LTCF residents outside of Canada reported a mean prevalence of diabetes of 18.5% (10). In this systematic review, only 16% of residents with diabetes were managed with oral medications alone (i.e. without insulin), whereas 39% received insulin (alone or in combination with oral antihyperglycemic agents), and nearly half received no antihyperglycemic therapy at all (10). These findings may have been confounded by the use of survey methods rather than electronic databases in the majority of studies examined; certainly, the low rate of oral antihyperglycemic agent use would not be expected in a Canadian LTCF. In contrast, a small Canadian survey of a LTCF reported the use of oral agents without insulin in 30% of residents, whereas insulin use was estimated as 45% (9). However, the data were not confirmed by electronic prescription records, and no information was available to characterize the intensity of insulin therapy used in this small sample.

The aim of our study was to describe trends in the prevalence and incidence of diabetes among patients newly admitted to LTCFs in the province of Saskatchewan between 2003 and 2011, and also to describe the overall use of diabetes medications after LTCF admission.

Section snippets

Data source

This study was based on information derived from health administrative databases from the province of Saskatchewan, Canada. Provincial government health care benefits cover approximately 99% of all residents in Saskatchewan. Excluded persons are those covered by the federal government, such as the Royal Canadian Mounted Police, Canadian Armed Forces and inmates in federal penitentiaries (11). Data from the Institutional Care Home (ISCH) database and prescription drug database as well as person

Results

In all, 44 846 patients were admitted to a LTCF between January 1, 2003, and December 31, 2011. Among these, 14 624 (32.6%) were at least 60 years of age on admission, remained in a LTCF for at least 6 months and were covered under the provincial health plan for at least 2 years before admission without any LTCF admissions during this period (Figure 1). The mean age of patients on their index admission date was 84.1 years (median 85.0 years, SD 7.9) and 64.4% were female.

Discussion

We conducted a descriptive analysis of diabetes prevalence and incidence along with diabetic medication use among a cohort of residents newly admitted to LTCFs in Saskatchewan between 2003 and 2011. Using the CCDSS definition of diabetes, the total number of cases (i.e. incident and prevalent cases) equalled 16.9% of all new admissions to LTCF. However, using a more sensitive definition (i.e. accepting a single diagnostic claim or an antihyperglycemic dispensation), the estimated diabetes

Conclusions

The prevalence of diabetes in Saskatchewan LTCFs is consistent with previous estimates among elderly populations. Overall, medication use appears favourable in the majority of cases as evidenced by substantial use of metformin and declining use of glyburide. Continued observation of LTCFs should be employed to ensure that this growing population receives safe and effective diabetes care. Future research should examine associations between changes in diabetes medication use and clinical outcomes

Author Disclosures

This study is based in part on deidentified data provided by the Saskatchewan Ministry of Health. The interpretation and conclusions contained herein do not necessarily represent those of the government of Saskatchewan or the Saskatchewan Ministry of Health.

Author Contributions

MWA wrote the manuscript; KM contributed to the writing of the manuscript. MWA and XL researched data. KM, LML, GT, YS, AC and DFB contributed to the discussion and reviewed and edited the manuscript.

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The transition of diabetes care from home to hospital, within the hospital, and upon discharge is fraught with gaps that can adversely affect patient safety and length of stay. We aimed to highlight the variability in care during these transitions and point out areas where research is needed.
A PubMed search was performed with a combination of search terms that pertained to diabetes, hyperglycemia, hospitalization, locations in the hospital, discharge to home or a nursing facility, and diabetes medications. Studies with at least 50 patients that were written in the English language were included.
With the exception of transitioning from intravenous insulin infusion to subcutaneous insulin and perhaps admission to the regular floors, few studies pointedly focused on transitions of care, leading us to extrapolate recommendations based on data from disparate areas of care in the hospital. There is evidence at every stage of care, starting from the entry into the hospital and ending with discharge home or to a facility, that patients benefit from having protocols in place guiding overall care.
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Self-Monitoring of Blood Glucose and Hypoglycemia-Related Hospitalization in a Population-Based Cohort of Canadian Patients With Type 1 or Type 2 Diabetes
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All measures of blood glucose test strip utilization increased markedly over the study period in a manner consistent with previously published studies (40-42). Earlier studies also showed that the use of high-risk oral hypoglycemic medications, such as glyburide, declined during this period (43). Based on our results, test strip reimbursement restrictions recently imposed by several governments and/or insurance providers (20,44,45) would not be expected to impact hypoglycemia-related health outcomes or health services use.
The aim of this work was to determine whether: 1) blood glucose test strip use in the population is associated with hypoglycemia hospitalization rates, and 2) blood glucose test strip use among individuals is associated with a reduced risk of hypoglycemia hospitalization.
Administrative databases from Saskatchewan, Canada, were used to ascertain population-level hypoglycemia hospitalizations and test strip utilization over the period from 1996 to 2014. For objective 1, a generalized linear model with generalized estimating equations was fit to provincial data stratified by age group, sex and year. For objective 2, a nested case-control study was conducted for a cohort of insulin users with diagnosed diabetes. Multivariable conditional logistic regression was used to test the association of test strip use with hospitalization, after adjusting for clinical and demographic factors and health services use. Odds ratios (ORs) and 95% confidence intervals (95% CIs) are reported.
A total of 5,166 hospitalizations for hypoglycemia were identified in the observation period. Annual glucose test strip use increased by over 350%; however, no association was found with provincial hypoglycemia hospitalization rate during the same period, even after controlling for all-cause hospitalizations and population demographics. In the case-control analysis, test strip use was not associated with hospitalization for hypoglycemia among insulin users (n=10,617; adjusted OR, 1.08; 95% CI, 0.88 to 1.31). A sensitivity analysis in an independent cohort of noninsulin users produced a similar finding (n=47,501; adjusted OR, 1.04; 95% CI, 0.55 to 1.94).
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Ces travaux visaient à déterminer si : 1) l’utilisation de bandelettes réactives pour l’auto-surveillance de la glycémie dans la population est associée aux taux d’hypoglycémie et d’hospitalisation; 2) l’utilisation de bandelettes réactives pour l’auto-surveillance de la glycémie chez les individus est associée à la réduction du risque d’hospitalisation pour hypoglycémie.
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Nous avons relevé 5166 hospitalisations pour hypoglycémie durant la période d’observation. L’utilisation annuelle de bandelettes réactives pour l’auto-surveillance de la glycémie a connu une augmentation de plus de 350 %. Toutefois, nous n’avons observé aucune association avec le taux provincial d’hospitalisation pour hypoglycémie au cours de la même période, même après avoir tenu compte des hospitalisations toutes causes confondues et des données démographiques sur la population. Dans l’analyse cas-témoins, l’utilisation des bandelettes réactives n’a pas été associée à l’hospitalisation pour hypoglycémie chez les utilisateurs d’insuline (n = 10 617; RIA ajusté, 1,08; IC à 95 %, de 0,88 à 1,31). Une analyse de sensibilité auprès d’une cohorte indépendante de non-utilisateurs d’insuline a généré des résultats similaires (n = 47 501; RIA ajusté, 1,04; IC à 95 %, de 0,55 à 1,94).
Nos résultats s’ajoutent aux nombreuses données probantes qui vont à l’encontre d’un effet protecteur de l’utilisation des bandelettes réactives pour l’auto-surveillance de la glycémie lors d’hypoglycémie sérieuse.
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Citation Excerpt :
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Self-rated knowledge and confidence were generally moderate to high, ranging from 46% to 79% being moderately to very knowledgeable and from 61% to 74% being moderately to very confident. Knowledge and confidence was highest for nutrition and management of hypo- and hyperglycemia and lower for sick-day management, oral medications and insulin. There were significant differences between clinicians such that PSWs reported less knowledge and confidence than RNs and RPNs on most parameters. Among the whole sample, 85% wanted education about diabetes, and this rate did not vary by occupation. The most commonly reported areas for additional education concerning diabetes were for management of hypo- and hyperglycemia (30% to 31%) and insulin (31%).
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Original ResearchTrends in Prevalence, Incidence and Pharmacologic Management of Diabetes Mellitus Among Seniors Newly Admitted to Long-Term Care Facilities in Saskatchewan between 2003 and 2011

Abstract

Objective

Methods

Results

Conclusions

Résumé

Objectif

Méthodes

Résultats

Conclusions

Introduction

Section snippets

Data source

Results

Discussion

Conclusions

Author Disclosures

Author Contributions

J Clin Epidemiol

Can J Diabetes

Can J Diabetes

Clin Ther

Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada

Can J Diabetes

American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults

J Am Geriatr Soc

Glycemic control of older adults with type 2 diabetes: Findings from the third National Health and Nutrition Examination Survey, 1988-1994

J Am Geriatr Soc

Diabetes in the frail elderly: Individualization of glycemic management

Can Fam Physician

Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas

Arch Intern Med

Original Research
Trends in Prevalence, Incidence and Pharmacologic Management of Diabetes Mellitus Among Seniors Newly Admitted to Long-Term Care Facilities in Saskatchewan between 2003 and 2011