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Low Blood Sugar Emergencies Usually Go Unreported in Medical Records

A study of diabetes patients at Kaiser Permanente points to nationwide need for improved tracking of severe hypoglycemic events

Andy Karter, PhD, Kaiser Permanente research scientist

Severe episodes of hypoglycemia occur far more often than is captured in electronic medical records, according to research published today in a JAMA Internal Medicine research letter by Kaiser Permanente and Yale School of Medicine researchers.

Patients with diabetes who take certain medications to lower their blood sugar are at risk for hypoglycemia, or low blood sugar reactions. Severe hypoglycemia occurs when blood sugar drops so low that a patient becomes confused or unconscious and needs assistance from another person to provide them with foods containing carbohydrates; an injection of glucagon, which quickly increases blood sugar levels; or a call to 911.

“A person experiencing severe hypoglycemia may receive assistance from a family member or another person and may or may not end up in the emergency department,” said lead author Andrew J. Karter, PhD, of the Kaiser Permanente Northern California Division of Research. “Unless the patient ends up using these emergency services, the event may never make it into the patient’s medical record.”

The new study, “Surveillance of Hypoglycemia—Limitations of Emergency Department and Hospital Utilization Data,” showed that medical records captured about one in twenty of the severe hypoglycemic events reported by 13,359 Kaiser Permanente Northern California members with diabetes who participated in a survey conducted by the Diabetes Study of Northern California (DISTANCE).

About 11 percent of survey participants reported a severe hypoglycemic event in response to the question, “In the past year, how many times have you had a severe low blood sugar reaction such as passing out or needing help to treat the reaction?” However, according to their electronic medical records, only about 0.5 percent of all participants visited an emergency room or were admitted to a hospital for hypoglycemia.

Capturing patient-reported outcomes could aid efforts to prevent hypoglycemia

“We were surprised that health care utilization was so uncommon relative to self-report,” Karter said. “National monitoring of severe hypoglycemia is based on data for emergency department and hospital utilization, which clearly underestimates the scope of this growing public health problem.”

The new findings point to the need for a way to reliably capture a patient’s experience of severe hypoglycemic events. Senior author Kasia Lipska, MD, MHS, of Yale School of Medicine is currently working to develop and validate a patient questionnaire for this purpose.

“Capturing patient-reported outcomes could further improve our ability to prevent hypoglycemia and increase safety, enhance current prediction models, and provide more comprehensive surveillance,” Lipska said. Still, she noted, it is important to continue monitoring severe hypoglycemia using electronic medical records, as this is the only way to currently gauge national hypoglycemia trends.

Funded by the National Institutes of Health, this research adds to a growing body of insights gleaned from DISTANCE, which launched in 2003 as a multifaceted effort to better understand social disparities in outcomes for diabetes patients. DISTANCE has revealed that limited health literacy and low socioeconomic status are associated with increased hypoglycemia risk and that African American diabetes patients have a particularly elevated risk of severe hypoglycemia.

“The ability to link patient-reported outcomes from our survey data to clinical data has been key to the success of the DISTANCE project,” Karter said. “Our new findings are a perfect example of this.”

Karter also recently led development of a new tool for clinicians to identify diabetes patients who face a high risk of severe hypoglycemia. While these new findings will not change the tool’s underlying algorithms, which rely on electronic medical records, Karter said that an improved ability to capture severe hypoglycemic events in medical records, including those that occur outside the walls of medical facilities, could one day improve the tool’s performance.

“Our study shines a spotlight on a key area that is ripe for improvement, and we are hopeful that improved tracking of low blood sugar emergencies will enhance public health policy and clinical decision-making,” Karter said.

Besides Lipska, Karter’s co-authors on the new study include Howard H. Moffet, MPH, and Jennifer Y. Liu, MPH, of the Kaiser Permanente Division of Research.

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