pp 1–9 | Cite as

Documentation of hypoglycemia assessment among adults with diabetes during clinical encounters in primary care and endocrinology practices

  • Rene Rodriguez-Gutierrez
  • Alejandro Salcido-Montenegro
  • Naykky M. Singh-Ospina
  • Spyridoula Maraka
  • Nicole Iñiguez-Ariza
  • Gabriela Spencer-Bonilla
  • Shrikant U. Tamhane
  • Kasia J. Lipska
  • Victor M. Montori
  • Rozalina G. McCoyEmail author
  • on behalf of the Hypoglycemia as a Quality Measure in Diabetes Study Group
Original Article



To examine the proportion of diabetes-focused clinical encounters in primary care and endocrinology practices where the evaluation for hypoglycemia is documented; and when it is, identify clinicians’ stated actions in response to patient-reported events.


A total of 470 diabetes-focused encounters among 283 patients nonpregnant adults (≥18 years) with type 1 or type 2 diabetes mellitus in this retrospective cohort study. Participants were randomly identified in blocks of treatment strategy and care location (95 and 52 primary care encounters among hypoglycemia-prone medications (i.e. insulin, sulfonylurea) and others patients, respectively; 94 and 42 endocrinology encounters among hypo-treated and others, respectively). Documentation of hypoglycemia and subsequent management plan in the electronic health record were evaluated.


Overall, 132 (46.6%) patients had documentation of hypoglycemia assessment, significantly more prevalent among hypo-treated patients seen in endocrinology than in primary care (72.3% vs. 47.4%; P = 0.001). Hypoglycemia was identified by patient in 38.2% of encounters. Odds of hypoglycemia assessment documentation was highest among the hypo-treated (OR 13.6; 95% CI 5.5−33.74, vs. others) and patients seen in endocrine clinic (OR 4.48; 95% CI 2.3−8.6, vs. primary care). After documentation of hypoglycemia, treatment was modified in 30% primary care and 46% endocrine clinic encounters; P = 0.31. Few patients were referred to diabetes self-management education and support (DSMES).


Continued efforts to improve hypoglycemia evaluation, documentation, and management are needed, particularly in primary care. This includes not only screening at-risk patients for hypoglycemia, but also modifying their treatment regimens and/or leveraging DSMES.


Hypoglycemia Type 2 diabetes Type 1 diabetes Primary care Healthcare quality Endocrinology 



We thank Darrell Schroeder from the Mayo Clinic Department of Medicine Clinical Research Office and Division of Biostatistics, who was instrumental in identifying patients meeting inclusion criteria for the study and randomly selecting participants for each cohort.

Author contributions

R.R.-G., V.M.M. and R.G.M. analyzed the data, designed the research and wrote the manuscript. R.R.-G., A.S.-M., N.M.S.-O., S.M., N.I.-A., G.S.-B., S.U.T., K.J.L., performed the research and analyzed the data and reviewed the manuscript. R.R.-G. and R.G.M. are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest. R.G.M. is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number K23DK114497. S.M. receives support by the Arkansas Biosciences Institute, the major research component of the Arkansas Tobacco Settlement Proceeds Act of 2000. K.J.L. receives support from the National Institute on Aging and the American Federation of Aging Research through the Paul Beeson Career Development Award (K23AG048359) and from CMS to develop and maintain publicly reported quality measures. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Mayo Clinic Institutional Review Board (reference number 10429) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    R. Rodriguez-Gutierrez, K.J. Lipska, R.G. McCoy, N. Singh Ospina, H.H. Ting, V.M. Montori, Hypoglycemia as an indicator of good diabetes care. BMJ 352, i1084 (2016)CrossRefGoogle Scholar
  2. 2.
    E. Ferrannini, S.J. Ramos, A. Salsali, W. Tang, J.F. List, Dapagliflozin monotherapy in type 2 diabetic patients with inadequate glycemic control by diet and exercise: a randomized, double-blind, placebo-controlled, phase 3 trial. Diabetes Care 33, 2217 (2010)CrossRefGoogle Scholar
  3. 3.
    American Diabetes Association (ADA), 6. Glycemic targets: standards of medical care in diabetes-2019. Diabetes Care 42(Supplement 1), S61 (2019)CrossRefGoogle Scholar
  4. 4.
    K. Khunti, M. Davies, A. Majeed, B.L. Thorsted, M.L. Wolden, S.K. Paul, Hypoglycemia and risk of cardiovascular disease and all-cause mortality in insulin-treated people with type 1 and type 2 diabetes: a cohort study. Diabetes Care 38, 316 (2015)CrossRefGoogle Scholar
  5. 5.
    R.G. McCoy, K.J. Lipska, X. Yao, J.S. Ross, V.M. Montori, N.D. Shah, Intensive treatment and severe hypoglycemia among adults with type 2 diabetes. JAMA Intern. Med. 55905, 1 (2016)Google Scholar
  6. 6.
    E. Marrett, L. Radican, M.J. Davies, Q. Zhang, Assessment of severity and frequency of self-reported hypoglycemia on quality of life in patients with type 2 diabetes treated with oral antihyperglycemic agents: a survey study. BMC Res. Notes 4, 251 (2011)CrossRefGoogle Scholar
  7. 7.
    R.A. Whitmer, A.J. Karter, K. Yaffe, C.P.J. Quesenberry, J.V. Selby, Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 301, 1565 (2009)CrossRefGoogle Scholar
  8. 8.
    T. Anderbro, L. Gonder-Frederick, J. Bolinder, P. Lins, R. Wredling, E. Moberg, J. Lisspers, U. Johansson, Fear of hypoglycemia: relationship to hypoglycemic risk and psychological factors. Acta Diabetol. 52, 581 (2015)CrossRefGoogle Scholar
  9. 9.
    R. Silbert, A. Salcido-Montenegro, R. Rodriguez-Gutierrez, A. Katabi, R.G. McCoy, Hypoglycemia among patients with type 2 diabetes: epidemiology, risk factors, and prevention strategies. Curr. Diab. Rep. 18, 53 (2018)CrossRefGoogle Scholar
  10. 10.
    S.P. Rauh, F. Rutters, B.L. Thorsted, Self-reported hypoglycaemia in patients with type 2 diabetes treated with insulin in the Hoorn Diabetes Care System Cohort, the Netherlands: a prospective cohort study. BMJ Open 6, e012793 (2016)CrossRefGoogle Scholar
  11. 11.
    J.N. Henderson, K.V. Allen, I.J. Dearyt, B.M. Frier, Hypoglycaemia in insulin-treated Type 2 diabetes: frequency, symptoms and impaired awareness. Diabet. Med. 21, 103 (2004)CrossRefGoogle Scholar
  12. 12.
    E.R. Seaquist, J. Anderson, B. Childs, P. Cryer, S. Dagogo-Jack, L. Fish, S.R. Heller, H. Rodriguez, J. Rosenzweig, R. Vigersky, Hypoglycemia and diabetes: a report of a workgroup of the american diabetes association and the endocrine society. J. Clin. Endocrinol. Metab. 98, 1845 (2013)CrossRefGoogle Scholar
  13. 13.
    A.J. Garber, M.J. Abrahamson, J.I. Barzilay, L. Blonde, Z.T. Bloomgarden, M.A. Bush, S. Dagogo-Jack, R.A. DeFronzo, D. Einhorn, V.A. Fonseca, J.R. Garber, W.T. Garvey, G. Grunberger, Y. Handelsman, I.H. B., P.S. Jellinger, J.B. McGill, J.I. Mechanick, P.D. Rosenblit, G.E. Umpierrez, Consensus Statement by the American Association of Clinical Endocrinologists and American College Of Endocrinology on the comprehensive type 2 diabetes management algorithm—2019 executive summary. Endocr. Pract. 25, 60 (2019)Google Scholar
  14. 14.
    VA/DoD clinical practice guideline for the management of type 2 diabetes mellitus in primary care [article online], 2017. Accessed 7 July 2019
  15. 15.
    NICE National Institute for Health and Care Excellence, type 2 diabetes in adults: management [article online], 2015. Accessed 7 July 2019
  16. 16.
    M.J. Davies, D.A. D’Alessio, J. Fradkin, W.N. Kernan, C. Mathieu, G. Mingrone, P. Rossing, A. Tsapas, D.J. Wexler, J.B. Buse, Management of hyperglycemia in type 2 diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 61, 2461 (2018)CrossRefGoogle Scholar
  17. 17.
    A. Cheung, T. Stukel, D. Alter, R. Glazier, V. Ling, X. Wang, B. Shah, Primary care physician volume and quality of diabetes care—a population-based cohort study. Ann. Intern. Med. 166, 240 (2017)CrossRefGoogle Scholar
  18. 18.
    M.E. Charlson, P. Pompei, K.A. Ales, C.R. MacKenzie, A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J. Chronic Dis. 40, 373 (1987)CrossRefGoogle Scholar
  19. 19.
    G. Leese, J. Wang, J. Broomhall, P. Kelly, A. Marsden, W. Morrison, B. Frier, A. Morris; DARTS/MEMO Collaboration, Frequency of severe hypoglycemia in patients with non-insulin-dependent diabetes mellitus treated with sulfonylureas or insulin. Endocr. Pract. 26, 1176 (2003)Google Scholar
  20. 20.
    A.P. Nunes, J. Yang, L. Radican, S.S. Engel, K. Kurtyka, K. Tunceli, S. Yu, K. Iglay, M.C. Doherty, D.D. Dore, Assessing occurrence of hypoglycemia and its severity from electronic health records of patients with type 2 diabetes mellitus. Diabetes Res. Clin. Pract. 121, 192 (2016)CrossRefGoogle Scholar
  21. 21.
    M. Munshi, C. Slyne, A. Segal, N. Saul, C. Lyons, K. Weinger, Simplification of insulin regimen in older adults and risk of hypoglycemia. JAMA Intern. Med. 176, 1023 (2016)CrossRefGoogle Scholar
  22. 22.
    R.G. McCoy, K.J. Lipska, J. Herrin, M.M. Jeffery, H.M. Krumholz, N.D. Shah, Hospital readmissions among commercially insured and Medicare advantage beneficiaries with diabetes and the impact of severe hypoglycemic and hyperglycemic events. J. Gen. Intern. Med. 32, 1097–1105 (2017)CrossRefGoogle Scholar
  23. 23.
    M.L. Maciejewski, X. Mi, J. Sussman, M. Greiner, L.H. Curtis, J. Ng, S.C. Haffer, E.A. Kerr, Overtreatment and deintensification of diabetic therapy among Medicare beneficiaries. J. Gen. Intern. Med. 33, 34 (2018)CrossRefGoogle Scholar
  24. 24.
    R. Kush, E. Helton, F. Rockhold, C. Hardison, Electronic health records, medical research, and the Tower of Babel. N. Engl. J. Med. 358, 1738 (2008)CrossRefGoogle Scholar
  25. 25.
    J. Gill, A.J. Foy, Y. Ling, Quality of outpatient care for diabetes mellitus in a national electronic health record network. Am. J. Med. Qual. 21, 13 (2006)CrossRefGoogle Scholar
  26. 26.
    UK Hypoglycaemia Study Group, Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia 50, 1140 (2007)CrossRefGoogle Scholar
  27. 27.
    L. Donnelly, A. Morris, B. Frier, J. Ellis, P. Donnan, R. Durrant, M. Band, G. Reekie, G. Leese; DARTS/MEMO Collaboration., Frequency and predictors of hypoglycaemia in Type 1 and insulin-treated Type 2 diabetes: a population-based study. Diabet. Med. 22, 749 (2005)CrossRefGoogle Scholar
  28. 28.
    M. Rendell, S. Saiprasad, A. Trepp-Carrasco, A. Drincic, The future of inpatient diabetes management: glucose as the sixth vital sign. Expert Rev. Endocrinol. Metab. 8, 195 (2013)CrossRefGoogle Scholar
  29. 29.
    R. Rodríguez-Gutiérrez, N. Singh Ospina, R.G. McCoy, K.J. Lipska, N.D. Shah, V.M. Montori; Hypoglycemia as a Quality Measure in Diabetes Study Group, Inclusion of hypogycemia in clinical practice guidelines and performance measures in the care of patients with diabetes. JAMA Intern. Med. 176, 1714 (2016)CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Rene Rodriguez-Gutierrez
    • 1
    • 2
    • 3
    • 4
  • Alejandro Salcido-Montenegro
    • 3
    • 4
  • Naykky M. Singh-Ospina
    • 1
    • 5
  • Spyridoula Maraka
    • 1
    • 6
  • Nicole Iñiguez-Ariza
    • 2
    • 7
  • Gabriela Spencer-Bonilla
    • 1
    • 8
  • Shrikant U. Tamhane
    • 2
  • Kasia J. Lipska
    • 9
  • Victor M. Montori
    • 1
    • 2
  • Rozalina G. McCoy
    • 10
    • 11
    • 12
    Email author
  • on behalf of the Hypoglycemia as a Quality Measure in Diabetes Study Group
  1. 1.Knowledge and Evaluation Research Unit in EndocrinologyMayo ClinicRochesterUSA
  2. 2.Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of MedicineMayo ClinicRochesterUSA
  3. 3.Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. JoséE. González”Universidad Autonoma de Nuevo LeonMonterreyMéxico
  4. 4.Plataforma INVEST Medicina UANL—KER Unit (KER Unit México), Subdirección de InvestigaciónUniversidad Autónoma de Nuevo LeónMonterreyMéxico
  5. 5.Division of Endocrinology, Department of MedicineUniversity of FloridaGainesvilleUSA
  6. 6.Division of Endocrinology and Metabolism, Center for Osteoporosis and Metabolic Bone DiseasesUniversity of Arkansas for Medical Sciences and the Central Arkansas Veterans Health Care SystemLittle RockUSA
  7. 7.Department of Endocrinology and MetabolismInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
  8. 8.Department of MedicineStanford University School of MedicineStanfordUSA
  9. 9.Section of Endocrinology, Department of Internal MedicineYale School of MedicineNew HavenUSA
  10. 10.Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterUSA
  11. 11.Division of Community Internal Medicine, Department of MedicineMayo ClinicRochesterUSA
  12. 12.Division of Health Care Policy & Research, Department of Health Sciences ResearchMayo ClinicRochesterUSA

Personalised recommendations