Glycemic Over- and Undertreatment in VA Nursing Home Residents with Type 2 Diabetes: a Retrospective Cohort Study

  • Lauren LederleEmail author
  • Bocheng Jing
  • Annette Rodriguez
  • Lauren J. Hunt
  • Sei J. Lee
Concise Research Report


For nursing home (NH) residents, clinical guidelines recommend less stringent hemoglobin A1c (HbA1c) targets between 7.5 and 9.0%1, 2, 3 while avoiding medications with higher hypoglycemia risks such as insulin. Previous studies in community-dwelling older adults have suggested that overly intensive glycemic treatment may be common.4, 5 However, little is known about current glycemic treatment practices among NH residents with type 2 diabetes mellitus (T2DM). Our objective was to determine the rates of glycemic overtreatment (defined as insulin use with HbA1c < 6.5%) and glycemic undertreatment (defined as no glucose-lowering medications with HbA1c ≥ 8.5%) in older adults recently admitted to the NH.


We conducted a retrospective cohort study of Veterans Affairs (VA) nursing home residents over age 65 with T2DM from January 1, 2013, to December 31, 2015. We defined diabetes as HbA1c > 6.5% or use of glucose-lowering medication (GLM) in the year prior to NH...


Compliance with ethical standards

This study was reviewed and approved by the University of California, San Francisco Committee on Human Research.

Conflict of interest

The authors have no conflicts of interest to report


  1. 1.
    Association AD. 11. Older Adults: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2018;41(Supplement 1):S119-S125.
  2. 2.
    Munshi MN, Florez H, Huang ES, et al. Management of diabetes in long-term care and skilled nursing facilities: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-318. Scholar
  3. 3.
    Conlin PR, Colburn J, Aron D, Pries RM, Tschanz MP, Pogach L. Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus. Ann Intern Med. 2017;167(9):655-663. Scholar
  4. 4.
    Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. 2015;175(3):356-362. Scholar
  5. 5.
    Tseng C-L, Soroka O, Maney M, Aron DC, Pogach LM. Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med. 2014;174(2):259-268. Scholar
  6. 6.
    Newton CA, Adeel S, Sadeghi-Yarandi S, et al. Prevalence, quality of care, and complications in long term care residents with diabetes: a multicenter observational study. J Am Med Dir Assoc. 2013;14(11):842-846. Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  1. 1.Division of Hospital MedicineSan Francisco VA Medical CenterSan FranciscoUSA
  2. 2.Division of GeriatricsUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.Department of Physiological NursingUCSFSan FranciscoUSA
  4. 4.Geriatrics and Extended Care ServiceSan Francisco VA Medical CenterSan FranciscoUSA

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