This page contains resources for clinicians categorized by the key focus areas of the VHA Choosing Wisely Hypoglycemia Safety Initiative (CW-HSI). Explore each section to find presentations, training modules, handouts, implementation examples, recommended reading, and more.
Hypoglycemia and Medication Safety
The VHA CW-HSI supports a voluntary program within VHA aimed at identifying a specific, manageable patient cohort at high risk for hypoglycemia who may be overtreated. The references and materials provided here describe components of this program. While representative of VA’s implementation, similar programs are possible in any health care system.
Experiences implementing the CW-HSI
- VISN 12 (VA Great Lakes Health Care System) & VHA: Wright SM, Hedin SC, McConnell M, Burke BV, Watts SA, Leslie DM, Aron DC, Pogach LM. Using shared decision-making to address possible overtreatment in patients at high risk for hypoglycemia: the Veterans Health Administration's Choosing Wisely Hypoglycemia Safety Initiative. Clin Diabetes 2018;36:120-127
- VISN 1 (VA New England Healthcare System): Vimalananda VG, DeSotto K, Chen T, et al. A quality improvement program to reduce potential overtreatment of diabetes among Veterans at high risk of hypoglycemia. Diabetes Spectr 2017;30:211–216
Things to Consider When Initiating the Choosing Wisely Hypoglycemia Safety Initiative (CW-HSI): one-page set of considerations to review prior to initiating the CW-HSI
Medication Safety in Seconds: “Ask about Lows” and Increasing Hypoglycemia Awareness and Promoting Shared Decision-Making through Education and Informatics Tools
Informatics tools have been integral to the success of the VHA CW-HSI program:
The CW-HSI Corporate Data Warehouse (CDW) reports (internal VA web site) include patients in the pre-determined CW-HSI cohort* as well as patients screened using the CW-HSI EMR template. An example of use of these reports is population health surveillance by care managers (e.g., clinical pharmacy specialists, certified diabetes educators) to identify and contact patients, often by a telephone call. *patients assigned to VA Primary Care with an active or recently expired prescription for insulin and/or sulfonylurea AND who have a most recent A1C in the last 18 months <7% (measure of potential overtreatment) AND who are either age 75 years or older, have dementia/cognitive impairment, or have a most recent serum creatinine in the last 18 months >1.7 mg/dl (risk factors for hypoglycemia)
EMR Clinical Decision Support
The VHA CW-HSI supports two EMR tools for clinicians in VHA: a clinical alert and a template. The clinical alert triggers in the EMR for patients who meet the cohort criteria in real time at the point of care (e.g., when patients come in for an appointment with their primary care provider), prompting assessment and management of hypoglycemia occurrence and risk. The template includes a set of questions to screen for and assess the occurrence, frequency, and severity of hypoglycemia and captures the care plan subsequently decided on through shared decision-making. The template was designed to be brief and easy to complete within the EMR during conversation with patients.
Prescription order alert for patients 65 years of age or older on insulin: description of a pharmacy order check that alerts prescribers when ordering insulin in a patient 65 years of age or older whose most recent A1C was <7.5%. Developed by VISN 21.
VHA Support Service Center (VSSC) has developed a Diabetes data cube, which can be found on the VSSC site (internal VA web site) in the Specialty Care Services section. The cube can assist clinicians and managers with improving diabetes care by identifying populations of patients who have diabetes and by providing additional clinical information such as comorbid conditions, lab results, pharmacy, and demographic data. The cube provides another tool for population health surveillance.
The Interprofessional Approach to Hypoglycemia Safety TMS Course (VA 31303) (for VA employees only): This knowledge based webinar will review management of patients at high risk for hypoglycemia. The purpose of this program is to promote recognition and prevention of serious hypoglycemia in high risk patients. This presentation reviews risk factors for hypoglycemia and discusses the medical complexities that contribute to that risk. In addition, participants will learn the actions that a multiprofessional team can take to reduce the risk of hypoglycemia. Audience: pharmacists, physicians, physician assistants, nurses, psychologists, dentists, counselors, social workers and dieticians; credit hours: 1 hour; accreditations: AAPA, ACCME, ACCME-NP, ACPE, ADA, ANCC, APA, ASWB, CDR, NBCC, NYSED SW.
Update on 2017 VA/DoD Diabetes Guidelines and VHA Hypoglycemia Safety Initiative (VA 34689; Nov 2017) (for VA employees only)
Preventing Adverse Drug Events: Individualizing Glycemic Targets Using Health Literacy Strategies is an eLearning course that teaches health care providers how to reduce hypoglycemic adverse drug events (ADEs) in patients with diabetes. Provided by HHS Office of Disease Prevention and Health Promotion (ODPHP).
Reducing the Risk of Preventable Adverse Drug Events associated with Hypoglycemia in the Older Population: FDA public workshop held September 12, 2017 to discuss the importance of individualized glycemic control targets for older patients with diabetes, identify and discuss medication safety efforts, and discuss future areas of research that could be explored to reduce the risk of serious hypoglycemia in this population.
A1C Testing, Variability, and TargetsA1C target ranges should be individualized and consider individual preferences, presence or absence of microvascular complications, and presence or severity of comorbid conditions. An extensive discussion of setting A1C targets is available in the VA/DoD Diabetes Guidelines and are briefly summarized here:
A lab test comment about individualizing target A1C values has been added to the results of all A1C lab tests performed in the VA:
Evidence-based, patient-centered, shared glycemic goals: screenshots of clinical decision support (VA “clinical reminder”) that prompts clinicians to individualize A1C goals and/or notify clinicians of patients at high risk of hypoglycemia. Developed by VISN 12.
- Abbasi J. For patients with type 2 diabetes, what's the best target hemoglobin A1C? JAMA 2018;319:2367-2369
- Burke BV, Hedin S. Brief commentary: laboratory accuracy of hemoglobin A1c ranges and treatment targets for patients with type 2 diabetes. Ann Intern Med 2018
The U.S. Department of Agriculture (USDA) defines food insecurity as a household-level economic and social condition of limited or uncertain access to adequate food. In 2016, an estimated 1 in 8 Americans were food insecure.
Food Insecurity and Its Impact on Diabetes Management: Identifying Interventions That Make a Difference: CDC National Diabetes Education Program (NDEP) webinar that focuses on defining food insecurity, its association with diabetes, and strategies that diabetes educators, health educators, and community health workers can use to help people with diabetes improve self-care.
Screening for Food Insecurity: information about the food insecurity screening section of the VA Homelessness and Food Insecurity clinical reminder.
Food Insecurity Assessment Tool and Resource List produced by the IHS Division of Diabetes Treatment and Prevention.
Shared decision-making is a model of patient-centered care that enables and encourages people to play a role in the medical decisions that affect their health (AHRQ SHARE Approach). It operates under two premises:
- First, consumers armed with good information can and will participate in the medical decision-making process by asking informed questions and expressing personal values and opinions about their conditions and treatment options.
- Second, clinicians will respect patients’ goals and preferences and use them to guide recommendations and treatments.
Partnering with Your Patient: Shared Decision Making Training TMS Course (VA 35040) (for VA employees only): This knowledge-based program will demonstrate the collaborative process by which patients and clinicians work together in a deliberative dialogue to address treatment options for diabetes, which affects 25% of the VA’s patient population. Shared decision making (SDM) is a patient-centered approach to improve the quality of care of patients with diabetes. Key principles of SDM include the patient readiness, provision of benefits and harms of all options using understandable tools, and incorporation of patient preferences. This module will explain the steps of shared decision making, identify those involved in the process and assist in understanding how to overcome barriers in implementing shared decision making into practice. Audience: physicians, nurses, pharmacists, and dietitians; credit hours: 0.5 hours; accreditations: ACCME, ACCME-NP, ACPE, ANCC.
- Aron DC, Conlin PR, Pogach L. Brief commentary: the glycemic target guideline controversy: same evidence, different perspectives, and a proposal for common ground. Ann Intern Med 2018