Emergency Department Visits for Hypoglycemia in Older Adults With Diabetes (EDH)

For persons 67 years of age and older with diabetes (types 1 and 2), the risk-adjusted ratio of observed to expected (O/E) emergency department (ED) visits for hypoglycemia during the measurement period. Two rates are reported:

  • For persons 67 years of age and older with diabetes (types 1 and 2), the risk-adjusted ratio of O/E ED visits for hypoglycemia during the measurement period, stratified by dual eligibility.
  • For persons 67 years of age and older with diabetes (types 1 and 2) who had at least one dispensing event of insulin within each 180-day (6-month) treatment period from July 1 of the year prior to the measurement period through December 31 of the measurement period, the risk-adjusted ratio of O/E ED visits for hypoglycemia, stratified by dual eligibility.

Why It Matters

The measure reports a total rate and a rate among members receiving insulin; both rates are stratified by dual eligibility status. Lower rates indicate better performance on this measure.

Patients with diabetes who experience a hypoglycemic event are at significantly higher risk of repeat severe hypoglycemic episodes, as well as other negative outcomes such as cardiovascular events (1). Common adverse events resulting from hypoglycemia include cardiovascular disease, falls and fractures, dementia, low health-related quality of life, potential risk of strokes and increased mortality (2,3,4). Hypoglycemia may be influenced by a variety of factors, including malnutrition or food insecurity (5,6), tight glycemic control and use of intensive antihyperglycemic medications (7,8).

Analysis of the Nationwide Emergency Department Sample found that in 2011, 2.2% of all ED visits experienced by adults with diabetes were related to hypoglycemia (9). Older adults with diabetes are at higher risk of hypoglycemia resulting from diabetes treatment than younger adults. A retrospective cohort study of over 160,000 patients with type 2 diabetes found the incidence rate of hypoglycemia among those 65–74 was almost twice as high compared to those 20–64, and over four times as high among those 75 and older. (11)

While the consequences of hypoglycemia can be devastating in older adults, it may be possible to reduce hypoglycemia risk through effective treatment management. Multiple clinical practice guidelines recommend adjusting treatment regimens in older adults to minimize hypoglycemia risk. For example, the American Diabetes Association (ADA) recommends routine monitoring of hypoglycemic episodes and adjusting glycemic targets and pharmacologic regimens to avoid hypoglycemia in older adults (12). The Endocrine Society recommends that clinicians design outpatient diabetes regimens specifically to minimize hypoglycemia (13). The AACE/ACE  cites minimizing hypoglycemia as a guiding principle in its diabetes treatment algorithm and emphasizes that reducing risk of hypoglycemia should be a key consideration when selecting antihyperglycemic agents (14).

Historical Results – National Averages

Performance results for this measure are currently unavailable. Visit our Quality Compass page to explore data licensing options and gain access to detailed performance results for this measure.

References

  1. O’Reilly, J.E., A. Jeyam, T.M. Caparrotta, P. McKeigue, & H. Colhoun. 2021. “The Association of Hypoglycaemia Exposure with Subsequent Adverse Events and Severe Hypoglycaemia: Preliminary Results from Hypo-RESOLVE.” In Diabetologia, vol. 64, no. suppl 1, pp. 40. One New York Plaza, Suite 4600, New York, NY: Springer, 2021. 
  2. Hart, H.E., G.E. Rutten, K.N. Bontje, & R.C. Vos. 2018. “Overtreatment of Older Patients with Type 2 Diabetes Mellitus in Primary Care.” Diabetes, Obesity and Metabolism 20, no. 4: 1066. https://doi.org/10.1111/dom.13174 
  3. Mattishent, K., & Y.K. Loke. 2016. “Meta-Analysis: Association between Hypoglycaemia and Serious Adverse Events in Older Patients.” Journal of Diabetes and its Complications 30, no. 5: 811–18. https://doi.org/10.1016/j.jdiacomp.2016.03.018 
  4. Zheng, B., B. Su, G. Price, I. Tzoulaki, S. Ahmadi-Abhari, & L. Middleton. 2021. “Glycemic Control, Diabetic Complications, and Risk of Dementia in Patients With Diabetes: Results From a Large UK Cohort Study.” Diabetes Care. 
  5. Abdelhafiz, A.H., L. Rodríguez-Mañas, J.E. Morley, & A.J. Sinclair. 2015. “Hypoglycemia in Older People – A Less Well Recognized Risk Factor for Frailty.” Aging and Disease 6, no. 2: 156–67. https://doi.org/10.14336/ad.2014.0330. 
  6. Seligman, H.K., A.F. Bolger, D. Guzman, A. López, & K. Bibbins-Domingo. January 2014. “Exhaustion of Food Budgets at Month’s End and Hospital Admissions for Hypoglycemia.” Health Affairs (Project Hope) 33, no. 1: 116–23. https://doi.org/10.1377/hlthaff.2013.0096 
  7. Yu, S., A.Z. Fu, S.S. Engel, R.R. Shankar, & L. Radican. 2016. “Association Between Hypoglycemia Risk and Hemoglobin A1C in Patients With Type 2 Diabetes Mellitus.” Current Medical Research and Opinion 32, no. 8: 1409–16. 
  8. Bodmer, M., C. Meier, S. Krähenbühl, S.S. Jick, & C.R. Meier. 2008. “Metformin, Sulfonylureas, or other Antidiabetes Drugs and the Risk of Lactic Acidosis or Hypoglycemia: A Nested Case-Control Analysis.” Diabetes care 31, no. 11: 2086–91. 
  9. Wang, J., L.S. Geiss, D.E. Williams, & E.W. Gregg. July 2015. “Trends in Emergency Department Visit Rates for Hypoglycemia and Hyperglycemic Crisis among Adults with Diabetes, United States, 2006-2011.” PLOS One 10, no. 8. https://doi.org/10.1371/journal.pone.0134917 
  10. Abdelhafiz, A.H., L. Rodríguez-Mañas, J.E. Morley, & A.J. Sinclair. 2015. “Hypoglycemia in Older People – A Less Well Recognized Risk Factor for Frailty.” Aging and Disease 6, no. 2: 156–67. https://doi.org/10.14336/ad.2014.0330. 
  11.  Ikeda, Y., T. Kubo, E. Oda, M. Abe, & S. Tokita. 2018. “Incidence Rate and Patient Characteristics of Severe Hypoglycemia in treated Type 2 Diabetes Mellitus Patients in Japan: Retrospective Diagnosis Procedure Combination Database Analysis.” Journal of Diabetes Investigation 9, no. 4 (2018): 925–36. 
  12.  American Diabetes Association. 2021. “12. Older Adults: Standards of Medical Care in Diabetes—2021.” Diabetes Care 44, no. Supplement 1. https://doi.org/10.2337/dc20-s012. 
  13.  Endocrine Society. 2019. “Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism 104, no. 5: 1520. https://doi.org/10.1210/jc.2019-00198 
  14.  Garber, A.J., Y. Handelsman, G. Grunberger, D. Einhorn, M.J. Abrahamson, J.I. Barzilay, L. Blonde, et al. 2020. “Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm—2020 Executive Summary.” Endocrine Practice 26, no. 1: 107. https://doi.org/10.4158/cs-2019-0472 

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