Ohio Veterans’ Facility Relied on AHRQ Resource to Develop Diabetes Initiative

The Dayton (Ohio) Veterans Affairs (VA) Medical Center facility has adopted AHRQ’s SHARE Approach as part of the U.S. Department of Veterans Affairs' national Hypoglycemic Safety Initiative to help high-risk diabetes patients get individual care quickly. The SHARE Approach is a curriculum that teaches healthcare professionals how to engage patients in their healthcare decision making. The facility uses it to support discussions between patients, family members, and healthcare teams about the possible treatment options that could most benefit the patient.  

People diagnosed with diabetes quickly learn to pay attention to their A1C levels. The A1C blood test measures average blood sugar levels over the previous 2 to 3 months. For most people, a good A1C reading is below seven. However, that may be too low for many older people with diabetes because they risk developing hypoglycemia (abnormally low blood sugar). Those at highest risk for hypoglycemia are patients over 75 years old with dementia or cognitive impairment and renal impairment. Hypoglycemia can cause weakness, fatigue, blurred vision, dizziness, and nausea.

“About half of our veterans with diabetes—around 500 patients—are at high risk for hypoglycemia,” said Brian Burke, M.D., an internal medicine physician who is chief of diabetes services at the Dayton VA Medical Center. “For these patients, general efforts to lower A1C levels only increase their risk for hypoglycemia. Older veterans often do not have typical signs or symptoms of low blood sugar, but more frequently develop confusion and weakness.”

To reduce the risk of hypoglycemia in these patients, Dr. Burke, Rebecca Dix, Pharm.D., and their colleagues created the Dayton VA Hypoglycemia Safety Initiative in 2017. In addition to using SHARE Approach training, they adopted an electronic tool that allows the healthcare team to monitor risk factors and patients’ A1C status. Patient care teams are trained in using AHRQ’s SHARE Approach to facilitate discussions with patients.

When risk factors are identified, patients have a conversation with VA healthcare providers, particularly clinical pharmacy specialists, to discuss reducing or changing their medication to reduce their risk of hypoglycemia. Clinical pharmacists can change medications and adjust dosages quickly, without a patient needing an additional visit with a primary care provider.

“We have found that having pharmacists work directly with patients is usually a huge relief to patients and their families,” said Dr. Dix. “Giving patients permission to loosen their strict diabetes control can make it a lot easier for them. And they feel much better when they don’t experience hypoglycemic episodes.”

She added, “Not only do our pharmacists use our screening tool, our primary care doctors also use it. But it really is the patient’s choice whether to reduce their medication. We want them involved as much as possible in making this decision.”

In 2017, the U.S. Departments of Veterans Affairs and Defense recognized the important role shared decision making plays in managing diabetes. Their Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care states that “when properly executed, [shared decision making] may decrease patient anxiety, increase trust in clinicians, and improve treatment adherence.”

Other VA facilities also are using AHRQ’s SHARE Approach to collaborate on diabetes care. Furthermore, Dr. Burke said, “We anticipate that this process will also be used for other areas of care. Shared decision making is something a lot of clinicians already do throughout the VA.”