BMJ 2016;352:i1084 doi: 10.1136/bmj.

i1084 (Published 7 March 2016) Page 1 of 4

Analysis

ANALYSIS

Hypoglycemia as an indicator of good diabetes care

Rene Rodriguez-Gutierrez and colleagues argue that more attention should be paid to
hypoglycemia when assessing management of diabetes

12 3
Rene Rodriguez-Gutierrez postdoctoral researcher , Kasia J Lipska assistant professor of medicine ,
4 5 1
Rozalina G McCoy assistant professor of medicine , Naykky Singh Ospina endocrinology fellow ,
6 1
Henry H Ting senior vice president , Victor M Montori, professor of medicine , Hypoglycemia as a
Quality Measure in Diabetes Study Group
1
Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic,
Rochester, MN 55905, USA; 2Division of Endocrinology, University Hospital Dr Jose E Gonzalez, Autonomous University of Nuevo Leon, Monterrey,
Mexico; 3Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA; 4Division of Primary Care Internal Medicine, Mayo Clinic,
Rochester, MN, USA; 5Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA; 6New York-Presbyterian Hospital, New
York, USA

The goals of diabetes care are to reduce the risk of short and
long term complications, increase longevity, and improve health
related quality of life. Tight glycemic control—aiming for a
hemoglobin A1c (HbA1c) concentration below 6.5-7.0%—has
been the cornerstone of diabetes care based on the results of
early randomized clinical trials that suggested a reduction in
microvascular and macrovascular complications.1 2 These trials
also found a twofold to threefold increase in the risk of severe
hypoglycemia among patients randomized to intensive glycemic
control.3 4 However, given the long term benefits of intensive
glycemic control, this risk seemed justified and some have
suggested a target for HbA1c “as close to normal as possible
(<6%).”5 6 For many patients, hypoglycemia is the limiting factor
to achieving stringent glycemic goals.5 7 It is also often perceived
an unavoidable burden that needs to be accepted in order to
accrue the potential long term benefits of glycemic control.
But this model of care is now changing, particularly in type 2
diabetes. The effect of tight glycemic control on microvascular
and macrovascular outcomes that are important to patients (end
stage renal disease, dialysis, blindness, clinical neuropathy,
stroke, and death) remains uncertain,8-11 making it increasingly
difficult for many patients and clinicians to accept the risk of
severe hypoglycemia. Furthermore, even mild episodes of
hypoglycemia (those that are self treated) impose a burden,
cause distress, and disrupt the ability of patients to perform
everyday activities.12 In addition, severe hypoglycemia is
associated with adverse outcomes such as death, cardiovascular
events, cognitive impairment, dementia, impaired autonomic
function, fall related fractures, poor quality of life, and increased
cost (table).12-21 Recent clinical diabetes guidelines advocate
assessment and prevention of hypoglycemia, including reducing
stringency of glycemic targets among patients at risk of severe
hypoglycemia.2 22 We propose that hypoglycemia be included
as a counterbalance measure of quality as an effort to fully
optimize and individualize glycemic control and thereby
improve the care of patients with diabetes.
Current quality measures in diabetes care
A key effort to standardize measurement and reporting of the
quality of care in diabetes came with the Diabetes Quality
Improvement Project (DQIP) in the early 2000s. The DQIP
proposed HbA1c <9.5% (80 mmol/mol); low density lipoprotein
(LDL) cholesterol ≤3.36 mmol/l (130 mg/dL); blood pressure
control (<140/90 mm Hg); annual foot, eye, and nephropathy
examination; smoking cessation counseling; annual HbA1c
testing; and biennial lipid profiles. These measures were later
used in the US Healthcare Effectiveness Data and Information
Set and have been widely adopted worldwide,23 including by
the National Committee for Quality Assurance and National
Quality Forum in the United States, and the National Institute
for Health and Care Excellence (NICE) in the United
Kingdom.24-26 The guidelines give little attention to
hypoglycemia. The International Diabetes Federation (IDF), an
umbrella organization of 230 national diabetes associations,
proposes more than 20 potential quality indicators, but none
targets hypoglycemia.27 NICE simply adds that patients who
have experienced severe hypoglycemia should be referred to a
specialist diabetes team.26 Only the Department of Veterans
Affairs has specifically focused on hypoglycemia with its recent
initiative promoting the formulation of a personal plan for
managing blood glucose.28

Correspondence to: V M Montori montori.victor@mayo.edu

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2016;352:i1084 doi: 10.1136/bmj.i1084 (Published 7 March 2016)
Towards hypoglycemia as a quality
measure
Quality measures are used for both accountability (such as pay
for performance programs) and to drive quality improvement.
Quality measures should be evidence based, reflect processes
or outcomes important to patients, have sufficient validity and
reliability, be feasible to collect and report, and be usable by
clinicians and patients.29
Most current quality measures in diabetes are based on processes
of care (eg, periodic measurement of HbA1c; annual screening
for nephropathy, neuropathy, and retinopathy; and aspirin use)
and intermediate or surrogate clinical outcomes (eg, achieving
prespecified thresholds of HbA1c, LDL cholesterol, and blood
pressure). Though such targets are easy to standardize, measure,
and report they neglect a key aspect of patient centered care:
safety.
Accordingly, hypoglycemia can be a measure of the safety of
optimizing glycemic control. Multiple factors suggest that
hypoglycemia is a useful measurement of quality. Hypoglycemia
is common and can affect most patients with type 1 diabetes
and many patients with type 2 diabetes treated with insulin or
insulin secretagogs. On average, patients have two to three
episodes of mild hypoglycemia and one episode of severe
hypoglycemia per year.30 31 These averages, however, do not
reflect the fact that most episodes occur in a few high risk
patients who tend to have more and more frequent episodes.32
Furthermore, although the incidence of chronic complications
of diabetes seems to be plateauing, hypoglycemia continues to
be a concern.30 33 Hypoglycemia can be prevented by increasing
the awareness of patients and clinicians, teaching patients self
management skills, and tailoring glycemic control targets and
tactics to reduce the risk of both hypoglycemia and
hyperglycemia.34 35 Its use as a quality measure could therefore
lead to improvements in safety. The outcome is also important
to patients, both acutely12 19 and in the long run.15 1617
An important criterion for a quality outcome is that it is
measurable. We can measure blood sugar levels, patients can
report symptoms, and episodes that lead to medical attention
can be captured through electronic medical records or claims.
Although no consensus on the definition of severe hypoglycemia
exists, most guidelines use an agreed definition of needing third
party assistance (not necessarily a medical professional).36
However, severe hypoglycemia episodes may be under-reported
by patients, who may risk losing their driving license or their
job.37 Milder episodes also represent a challenge. Blood glucose
meters and continuous glucose monitoring devices can capture
hypoglycemia in patients who self monitor. Nevertheless, wide
consensus on evidence based definitions for mild and severe
hypoglycemia is needed.38
Although it is premature to specify which quality measures will
best address hypoglycemia, processes related to its prevention
could serve as quality measures. These include assessment for
hypoglycemia at every visit, change in the diabetes treatment
program in response to a hypoglycemic episode, education for
patients to prevent hypoglycemia, and prompt detection and
treatment of events. Actions could also include education of
patients on how to respond to hypoglycemia, use of a medical
alert bracelet or similar identification, and prescription of
glucose tablets or glucagon. Arguably, current quality measures
do not promote improvements in the implementation of these
measures. While not all of these measures are pertinent to every
patient with type 1 and type 2 diabetes, some should be focused
on the care of people at high risk of hypoglycemia—that is,
patients who have experienced hypoglycemia.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 2 of 4
ANALYSIS
Unintended consequences
Although the rationale to implement hypoglycemia as a quality
measure is compelling, its implementation could be associated
with unintended consequences that could affect the quality of
care. As an example, in a misguided attempt to prevent
hypoglycemia, HbA1c levels could rise in some patients to the
level of symptomatic hyperglycemia. The cost of care may be
increased by shifting to newer and more expensive drugs that
are less likely to cause hypoglycemia, although there is no
definitive evidence that such agents are truly better.39 Insulin
use could be delayed or complex insulin regimens used less
frequently. Self monitoring and the use of expensive continuous
glucose devices may increase (or decrease if they “worsen” a
quality measure used to document hypoglycemia), increasing
the burden of treatment for some. In addition, the burden of
measurement on practice and on the workload of clinicians may
increase.
The risk of unintended consequences could be reduced by
educating patients and clinicians that optimal glycemic control
requires balancing hyperglycemia and hypoglycemia. As an
example, loosening target goals in clinical practice guidelines
to an HbA1c of 7.0-8.5%, rather than picking a tight cut-off may
be helpful in optimising glycemic control. In future, the burden
of measurement could be reduced by using automated data from
electronic health records, rather than requiring manual extraction
from charts. Nevertheless, the selection of quality measures for
hypoglycemia processes will require careful research and
judicious implementation. Appropriate measures could advance
quality measurement in diabetes and improve the care for
millions of patients with diabetes.
Other members of the Hypoglycemia as a Quality Measure in Diabetes
Study Group are: Yogish C Kudva, Mark E McConnell, and Nilay D
Shah.
Contributors and sources: RRG, KJL, RGM, NSO, and VMM are
endocrinologists and health services researchers with special interest
in patient centered diabetes care. HHT is a cardiologist with extensive
experience in quality of care. The article resulted from discussions about
the burden of living with treatment-induced hypoglycemia and its
noticeable absence from most quality improvement initiatives. RRG and
VMM conceived the idea. RRG drafted the manuscript. All authors (KJL,
RGM, NSO, HHT, and VMM) contributed to manuscript critical appraisal
and review. All authors had full access to all of the data and take
responsibility for the integrity of the data and the accuracy of data
analysis.
Competing interests: We have read and understood BMJ policy on
declaration of interests and declare KJL receives support from CMS to
develop and maintain publicly reported quality measures.
Provenance and peer review: Not commissioned; externally peer
reviewed.
1 Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American
Association of Clinical Endocrinologists and American College of Endocrinology on the
comprehensive type 2 diabetes management algorithm—2016 executive summary. Endocr
Pract 2016;22:84-113. doi:10.4158/EP151126.CS. 26731084.
2 National Institute for Health and Care Excellence. Type 2 diabetes in adults: management:
NICE, 2015. www.nice.org.uk/guidance/ng28
3 Diabetes Control and Complications Trial Research Group. The effect of intensive
treatment of diabetes on the development and progression of long-term complications in
insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86. doi:10.1056/
NEJM199309303291401. 8366922.
4 UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with
sulphonylureas or insulin compared with conventional treatment and risk of complications
in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53. doi:10.1016/
S0140-6736(98)07019-6. 9742976.
5 American Diabetes Association. Standards of medical care in diabetes. Diabetes Care
6
2005;28(suppl 1):S4-36. doi:10.2337/diacare.28.suppl_1.S4. 15618112.
Jellinger PS, Smith DA, Mehta AE, et al. American Association of Clinical Endocrinologists’
guidelines for management of dyslipidemia and prevention of atherosclerosis. Endocr
Pract 2012;18(suppl 1):1-78doi:10.4158/EP.18.S1.1. .
Subscribe: http://www.bmj.com/subscribe
BMJ 2016;352:i1084 doi: 10.1136/bmj.i1084 (Published 7 March 2016)
Key messages
Quality measures for diabetes have focused on hyperglycemia at the expense of hypoglycemia
Hypoglycemia disrupts patients’ lives and is associated with adverse health outcomes
Measures designed to detect, prevent, and promptly treat hypoglycemia are needed
7 Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of type I and
type II diabetes. Diabetologia 2002;45:937-48. doi:10.1007/s00125-002-0822-9. 12136392.
8 Yudkin JS, Richter B, Gale EA. Intensified glucose lowering in type 2 diabetes: time for
a reappraisal. Diabetologia 2010;53:2079-85. doi:10.1007/s00125-010-1864-z. 20686748.
9 Montori VM, Fernández-Balsells M. Glycemic control in type 2 diabetes: time for an
evidence-based about-face?Ann Intern Med 2009;150:803-8. doi:10.7326/0003-4819-
150-11-200906020-00008. 19380837.
10 Hemmingsen B, Lund SS, Gluud C, et al. Targeting intensive glycaemic control versus
targeting conventional glycaemic control for type 2 diabetes mellitus. Cochrane Database
Syst Rev 2013;11:CD008143.24214280.
11 Coca SG, Ismail-Beigi F, Haq N, Krumholz HM, Parikh CR. Role of intensive glucose
control in development of renal end points in type 2 diabetes mellitus: systematic review
and meta-analysis intensive glucose control in type 2 diabetes. Arch Intern Med
2012;172:761-9. doi:10.1001/archinternmed.2011.2230. 22636820.
12 Green AJ, Fox KM, Grandy S. SHIELD Study Group. Self-reported hypoglycemia and
impact on quality of life and depression among adults with type 2 diabetes mellitus.
Diabetes Res Clin Pract 2012;96:313-8. doi:10.1016/j.diabres.2012.01.002. 22296853.
13 Bonds DE, Miller ME, Bergenstal RM, et al. The association between symptomatic, severe
hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis
of the ACCORD study. BMJ 2010;340:b4909. doi:10.1136/bmj.b4909. 20061358.
14 Zoungas S, Patel A, Chalmers J, et al. ADVANCE Collaborative Group. Severe
hypoglycemia and risks of vascular events and death. N Engl J Med 2010;363:1410-8.
doi:10.1056/NEJMoa1003795. 20925543.
15 McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA. Increased
mortality of patients with diabetes reporting severe hypoglycemia. Diabetes Care
2012;35:1897-901. doi:10.2337/dc11-2054. 22699297.
16 Goto A, Arah OA, Goto M, Terauchi Y, Noda M. Severe hypoglycaemia and cardiovascular
disease: systematic review and meta-analysis with bias analysis. BMJ 2013;347:f4533.
doi:10.1136/bmj.f4533. 23900314.
17 Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP Jr, , Selby JV. Hypoglycemic episodes
and risk of dementia in older patients with type 2 diabetes mellitus. JAMA
2009;301:1565-72. doi:10.1001/jama.2009.460. 19366776.
18 Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related
hypoglycemia and errors leading to emergency department visits and hospitalizations.
JAMA Intern Med 2014;174:678-86. doi:10.1001/jamainternmed.2014.136. 24615164.
19 McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA. Self-report
of hypoglycemia and health-related quality of life in patients with type 1 and type 2 diabetes.
Endocr Pract 2013;19:792-9. doi:10.4158/EP12382.OR. 23757608.
20 Johnston SS, Conner C, Aagren M, Ruiz K, Bouchard J. Association between
hypoglycaemic events and fall-related fractures in Medicare-covered patients with type
2 diabetes. Diabetes Obes Metab 2012;14:634-43. doi:10.1111/j.1463-1326.2012.01583.
x. 22335246.
21 Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for
adverse drug events in older Americans. N Engl J Med 2011;365:2002-12. doi:10.1056/
NEJMsa1103053. 22111719.
22 American Diabetes Association. 5. Glycemic targets. Diabetes Care 2016;39(suppl
1):S39-46. doi:10.2337/dc16-S008. 26696679.
23 Fleming BB, Greenfield S, Engelgau MM, Pogach LM, Clauser SB, Parrott MA. The
diabetes quality improvement project: moving science into health policy to gain an edge
on the diabetes epidemic. Diabetes Care 2001;24:1815-20. doi:10.2337/diacare.24.10.
1815. 11574448.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 3 of 4
ANALYSIS
24 National Committee for Quality Assurance. Diabetes recognition program (DRP), 2015.
http://www.ncqa.org/Programs/Recognition/ChangestoDRP.aspx
25 National Quality Forum. Endocrine Measures, 2014. http://www.qualityforum.org/projects/
endocrine/?section=CandidateConsensusStandardsReview2013-12-092014-04-02
26 National Institute for Health and Care Excellence. Diabetes in adults. Quality standard.
2011. https://www.nice.org.uk/guidance/qs6/chapter/List-of-statements-
27 International Diabetes Federation, Clinical Guidelines Task Force. Global guideline for
type 2 diabetes. IDF, 2012.
28 US Department Veterans Affairs. Hypoglycemia safety initiative (HSI), 2015. http://www.
qualityandsafety.va.gov/ChoosingWiselyHealthSafetyInitiative/HypoglycemiaSite/
Hypoglycemia.asp
29 National Quality Forum. Consensus task force. 2011. https://www.qualityforum.org/
Measuring_Performance/Improving_NQF_Process/Consensus_Task_Force.aspx
30 Frier BM. Hypoglycaemia in diabetes mellitus: epidemiology and clinical implications. Nat
Rev Endocrinol 2014;10:711-22. doi:10.1038/nrendo.2014.170. 25287289.
31 UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects
of treatment modalities and their duration. Diabetologia 2007;50:1140-7. doi:10.1007/
s00125-007-0599-y. 17415551.
32 Diabetes Control and Complications Trial Research Group. Hypoglycemia in the Diabetes
Control and Complications Trial. Diabetes 1997;46:271-86. doi:10.2337/diab.46.2.
271. 9000705.
33 Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United
States, 1990-2010. N Engl J Med 2014;370:1514-23. doi:10.1056/
NEJMoa1310799. 24738668.
34 Crasto W, Jarvis J, Khunti K, et al. Multifactorial intervention in individuals with type 2
diabetes and microalbuminuria: the Microalbuminuria Education and Medication
Optimisation (MEMO) study. Diabetes Res Clin Pract 2011;93:328-36. doi:10.1016/j.
diabres.2011.05.008. 21640424.
35 Miller ME, Bonds DE, Gerstein HC, et al. ACCORD Investigators. The effects of baseline
characteristics, glycaemia treatment approach, and glycated haemoglobin concentration
on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD
study. BMJ 2010;340:b5444. doi:10.1136/bmj.b5444. 20061360.
36 Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: a report of a
workgroup of the American Diabetes Association and the Endocrine Society. Diabetes
Care 2013;36:1384-95. doi:10.2337/dc12-2480. 23589542.
37 Pedersen-Bjergaard U, Færch L, Allingbjerg ML, Agesen R, Thorsteinsson B. The influence
of new European Union driver’s license legislation on reporting of severe hypoglycemia
by patients with type 1 diabetes. Diabetes Care 2015;38:29-33. doi:10.2337/dc14-
1417. 25288675.
38 Geelhoed-Duijvestijn PH, Pedersen-Bjergaard U, Weitgasser R, Lahtela J, Jensen MM, Östenson CG.
Effects of patient-reported non-severe hypoglycemia on healthcare resource use, work-time
loss, and wellbeing in insulin-treated patients with diabetes in seven European countries.
J Med Econ 2013;16:1453-61. doi:10.3111/13696998.2013.852098. 24144009.
39 Zhang Y, McCoy RG, Mason JE, Smith SA, Shah ND, Denton BT. Second-line agents
for glycemic control for type 2 diabetes: are newer agents better?Diabetes Care
2014;37:1338-45. doi:10.2337/dc13-1901. 24574345.
Accepted: 05 02 2016
Published by the BMJ Publishing Group Limited. For permission to use (where not already
granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2016;352:i1084 doi: 10.1136/bmj.i1084 (Published 7 March 2016) Page 4 of 4

ANALYSIS

Table

Table 1| Adverse outcomes (implications) of hypoglycemia that are important to patients

Adverse outcome Study

Death
Cardiovascular events
Neurologic sequelae
Quality of life
Fall related fractures
Emergency department visits and Geller et al18
hospital admission
ACCORD13
10 194 of the 10 251 participants enrolled in the ACCORD study who had at least one assessment for hypoglycemia during
regular follow-up. More participants in the intensive arm than the standard arm experienced an episode of severe hypoglycemia
(816 (15.9%) v 256 (5%)) or severe hypoglycemia requiring medical assistance (528 (10.3%) v 175 (3.4%)). Adjusted hazard
ratio for death was 1.41, 95% CI 1.03 to 1.93 in intensive group and 2.30, 95% CI 1.46 to 3.65
ADVANCE, 14
Median follow-up of 5 years, 231 patients (2.1%) had at least one severe hypoglycemic episode; 150 had been assigned to
intensive glucose control (2.7% of the 5571), and 81 had been assigned to standard glucose control (1.5% of the 5569)
Significant increase in death from any cause (HR=2.69; 95% CI 1.97 to 3.67)
McCoy et al, 15
1013 patients with type 1 (21.3%) and type 2 (78.7%) diabetes were questioned about hypoglycemia. Among these, 625 (61.7%)
reported any hypoglycemia, and 76 (7.5%) reported severe hypoglycemia
After 5 years, patients who reported severe hypoglycemia had 3.4-fold higher mortality (95% CI 1.5 to 7.4) than those who
reported mild/no hypoglycemia
ADVANCE14
Severe hypoglycemia was associated with a significant increase in the adjusted risks of major macrovascular events (HR=2.88,
95% CI 2.01 to 4.12) and death from a cardiovascular cause (2.68, 1.72 to 4.19)
Goto et al, 16
Six eligible studies with 903 510 participants were included in the analysis.
Severe hypoglycemia was strongly associated with a higher risk of cardiovascular disease (RR=2.05, 95% CI 1.74 to 2.42) .
Most subgroups showed similar results in stratified analyses
Whitmer et al17
A longitudinal cohort study from 1980-2007 of 16 667 patients with type 2 diabetes (mean age 65). Compared with patients
with no hypoglycemia, patients with single or multiple episodes had a graded increase in risk of dementia after full adjustment:
1 episode HR=1.26 (95% CI 1.10 to 1.49); 2 episodes 1.80 (1.37 to 2.36); and ≥3 episodes 1.94 (1.42 to 2.64)
Geller et al, 18
8100 National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance cases. Severe neurologic
sequelae were documented in an estimated 60.6% (95% CI 51.3% to 69.9%) of emergency department visits for insulin related
hypoglycemia
Green et al12
Of the 2718 patients with type 2 diabetes respondents, 23% reported hypoglycemia in past 12 months. Patients reporting
hypoglycemia (n=627) had lower SF-12 scores for both physical health (mean ±SD: 37.4±12.7 v 40.9±12.7) and mental health
(50.1±11.7 v 52.4±10.1) compared with those without hypoglycemia (n=2091). Mean PHQ-9 scores were higher among
respondents reporting hypoglycemia (5.2±5.8) than for respondents who did not report hypoglycemia (3.9±5.0), indicating
greater depression burden
McCoy et al, 19
Survey was completed by 418 patients (47.8% response rate). 26 of 92 (28.3%) respondents with type 1 and 55 of 326 (16.9%)
with type 2 diabetes reported at least one episode of severe hypoglycemia within the previous 6 months
Fear of hypoglycemia, including engagement in anticipatory avoidance behaviors, was highest in patients with type 2 diabetes
reporting severe hypoglycemia and all patients with type 1 diabetes (P<0.001). HRQoL was lower in patients with type 2 (but
not type 1) diabetes reporting severe hypoglycemia (P<.01)
Johnston et al20
361 210 included patients, 16 936 had hypoglycemic events during the evaluation period
Patients with hypoglycemic events had 70% higher regression adjusted odds (1.70, 95% CI 1.58 to1.83) of fall related fractures
than patients without hypoglycemic events
97 648 (95% CI 64 410 to130 887) emergency department visits for insulin related hypoglycemia occurred annually; 29.3%
(95% CI 21.8% to36.8%) resulted in admission
Budnitz et al, 21
In 5077 cases, there was an estimated 99 628 emergency admissions (95% CI 55 531to 143 724) for adverse drug events
Four medications or medication classes were implicated alone or in combination in 67% (95% CI 60% to 74.1%) of admissions:
warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%)

ACCORD, Action to Control Cardiovascular Risk in Diabetes; ADVANCE, Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled
Evaluation; HR, hazard ratio; CI, confidence interval; RR, relative risk; SF-12, short form-12; PhQ-9, patient health questionnaire-9; HRQoL, health related quality
of life.

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe