Effective treatment of diabetes requires a major shift in approach toward greater personalization of treatments based on potential for individual risk and benefit, according to a new study.
The study, published in the Journal of General Internal Medicine, found that although overly aggressive treatment of blood sugar in older people with diabetes can be harmful, it’s still common, and that providers and patients should work together to scale back diabetes treatment.
A team of researchers from the VA hospitals in Durham, North Carolina and Ann Arbor, Michigan, Duke University, and the University of Michigan, studied 78,792 Medicare participants over age 65 years in 10 states, all of whom had diabetes. The researchers used 2011 Medicare claims data and linked them to 2011 data from a large national laboratory vendor to be able to identify over-treatment and under-treatment on the basis of medication data and diabetes control from lab data. In those who appeared to be over-treated, they were able to examine de-intensification following the date of the lab value that indicated well-controlled diabetes with more than enough medication to control it.
The study found that almost 11% of Medicare participants with diabetes had very low blood sugar levels that suggested they were being over-treated. But only 14% of these patients had a reduction in blood sugar medication refills in the next six months.
Patients older than aged 75 years, and those who qualified for both Medicare and Medicaid because of low incomes or serious disability, were most likely to be over-treated. Those who lived in urban areas or were of Hispanic origin were less likely to be over-treated. Patients older than aged 75 years were less likely than others to have their treatment dialed back, as measured by prescription doses and refills.
But patients who had more than six chronic conditions, or who lived in urban areas or had frequent outpatient visits, were more likely to experience a de-intensification.
Balance the risks
“Treating diabetes requires balancing the risks of long-term harm from under-treatment with the short-term and long-term harm from potential over-treatment,” says study coauthor Jeremy Sussman, MD, MS, assistant professor at the University of Michigan and research scientist and physician at VA Ann Arbor Healthcare System. “Randomized trials have shown that the benefits of aggressive glycemic control only begin after at least eight years of treatment. Yet, the harms of aggressive glycemic control—hypoglycemia, cardiovascular events, cognitive impairment, fractures, and death—can happen at any time.”
In some older people, he says, “de-intensification” of diabetes treatment may be safer, because of the risks that come with too-low blood sugar. According to the American Geriatrics Society (AGS), medications other than metformin should be avoided when an older patient’s hemoglobin A1c is less than 7.5%, because the risks of hypoglycemia are larger and the potential benefits of treatment are smaller for older adults with diabetes.
“Most attention in prior work has focused on under-treatment of diabetes and there has been only limited investigation of patient characteristics associated with overtreatment of diabetes or severe hypoglycemia,” says Sussman.
“The medical community’s focus on under-treatment has resulted in dramatic improvements in glycemic control, on average, but has apparently also encouraged overtreatment,” says Sussman. “Effective treatment of diabetes requires a major shift in approach towards greater personalization of treatments based on potential for individual risk and benefit. Our study points the way for how to identify patients who may benefit not only from more intensive treatment, but also those who may need de-intensification.”
The researchers agree that in diabetes, both over-treatment and under-treatment are concerns.
“The same attention we’ve placed on the population health management of overtreatment could be placed on under-treatment,” says study author Matthew Maciejewski, PhD, research career scientist at the Durham VA and a professor in the department of population health sciences at Duke University.
Based on the study, Maciejewski and Sussman offer four recommendations to managed care executives:
1. Identify patients who are at risk of over-treatment and alert providers.
2. Add a focus on over-treatment to diabetes patient education programs or to clinician continuing education programs.
3. Develop clinician detailing systems about the risk of over-treatment.
4. Create automated reminders for all patients who go to the emergency room for hypoglycemia or who are on insulin but have too-tight diabetes control.
"By focusing at both the over-treatment and under-treatment ends of the diabetes quality spectrum, we can best begin to truly improve the quality of diabetes care, ensuring that patients get needed care while avoiding unnecessary potential harm,” Sussman says.