379-P: Don’t Ask, Don’t Tell—How Primary Care Is Failing to Address Fear of Hypoglycemia Free

Fear of hypoglycemia (FOH) contributes to medication nonadherence and lower quality of life, and may be unrecognized by clinicians. We conducted the first multicenter study examining how primary care providers (PCPs) address FOH. This mixed methods study examined audio-recorded visits between patients using hypoglycemia-causing medications (N=237) and their PCPs (N=50) at 4 geographically diverse Veterans Affairs medical centers from 2017-2020. Two investigators independently coded transcripts to identify discussions related to FOH and analyzed the dialogue using a directed content analysis approach. Results: participants’ mean age was 67 years, 89% were male, and 66% and 42% used insulin and sulfonylureas, respectively. FOH was not assessed by the PCP in any of the 237 visits. FOH was reported by 16 patients (6.8%) unprompted (“I met a lady coming the other day, her sugar dropped and she didn't make it. So that's why I was scared”). Among patients who expressed FOH, 88% reported a recent hypoglycemic event, and half stated that it prevented them from taking their medications (“I’m scared to take my medicine because I don’t want it to go down too low”). In response to FOH, most PCPs gathered hypoglycemia history (n=13) or counseled for prevention (n=11). Some PCP’s responded by moving to a new topic (n=2), or by chastising the patient (n=2) (“You're just using the insulins erratically⋯ It's dangerous, Mr. [name]. We keep reminding you”). Two PCPs provided validation (“It’s very scary probably”); no PCP explored the impact on the patient’s life. In conclusion, FOH is likely under-recognized in primary care as PCPs do not assess for it. Patients reporting FOH often struggle to take their diabetes medications as directed. PCPs respond to FOH by appropriately seeking to prevent recurrent events, but there are missed opportunities to provide support and empathy. Greater awareness, routine assessment, and empathy for at-risk patients who fear hypoglycemia is needed to improve diabetes management in primary care.