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Do Clinical Standards for Diabetes Care Address Excess Risk for Hypoglycemia in Vulnerable Patients? A Systematic Review


Address correspondence to Seth A. Berkowitz, M.D., Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA 02114; e-mail:



To determine whether diabetes clinical standards consider increased hypoglycemia risk in vulnerable patients.

Data Sources

MEDLINE, the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, and supplemental sources.

Study Design

Systematic review of clinical standards (guidelines, quality metrics, or pay-for-performance programs) for glycemic control in adult diabetes patients. The primary outcome was discussion of increased risk for hypoglycemia in vulnerable populations.

Data Collection/Extraction Methods

Manuscripts identified were abstracted by two independent reviewers using prespecified inclusion/exclusion criteria and a standardized abstraction form.

Principal Findings

We screened 1,166 titles, and reviewed 220 manuscripts in full text. Forty-four guidelines, 17 quality metrics, and 8 pay-for-performance programs were included. Five (11 percent) guidelines and no quality metrics or pay-for-performance programs met the primary outcome.


Clinical standards do not substantively incorporate evidence about increased risk for hypoglycemia in vulnerable populations.