Medicare recipients with diabetes may often be over-treated, according to a study published in the Journal of General Internal Medicine.
To avoid overtreatment, researchers concluded, clinicians and older patients must work together to achieve successful personalization and de-intensification of their treatment, a much safer route that may alleviate the inherent risks of hypoglycemia
Experts have recently suggested that clinicians dial back the intensity of how they treat patients aged 70 years and older for both high blood pressure and diabetes. Older adults often have trouble recognizing the signs of hypoglycemia, including confusion and combativeness. They may also struggle with multiple medications. The added responsibility of regularly monitoring their glucose levels can just magnify their struggles. Thus, de-intensifying treatment may provide a welcome respite for them.
Intensive diabetes control is mostly focused on long-term results.
“Every guideline for physicians has detailed guidance for prescribing and stepping up or adding drugs to control these risk factors, and somewhere toward the end it says ‘personalize treatment for older people’,” said study co-author Jeremy Sussman, MD, MS, research scientist, Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, and assistant professor, department of internal medicine, University of Michigan Medical School, Ann Arbor, MI. “But nowhere do they say actually stop medication in the oldest patients to avoid hypoglycemia or too-low blood pressure.”
In this study, Dr. Sussman and colleagues sought to determine the rates of overtreatment and de-intensification of therapy for older adults with diabetes, and whether there were differences according to medical, demographic, and socioeconomic characteristics.
They analyzed Medicare claims data from 10 states that were linked to outpatient laboratory values, to identify those patients who were potentially over-treated for diabetes, which they defined as individuals with an HbA1c < 6.5% with fills for any diabetes medications beyond metformin from Jan 1, 2011, through June 30, 2011.
Among the 78,792 Medicare recipients with diabetes, 10.9% were identified as potentially over-treated. Dr. Sussman and fellow researchers found that overtreatment of diabetes was more common in individuals aged > 75 years old and enrolled in Medicaid (P < 0.001), and less common in Hispanics (P=0.009).
In 14% of over-treated diabetics, therapy was de-intensified, and appropriate de-intensification was more common in patients with six or more chronic conditions, those with more outpatient visits, and those living in urban areas. De-intensification was less common in those over age 75. In all, only 6.9% of Medicare recipients with diabetes were potentially undertreated, with A1c levels > 9.
Finally, they found that the variables that were associated with overtreatment differed from those associated with undertreatment.
“The oldest Medicare beneficiaries are the least likely to benefit from tight glycemic control and most likely to be harmed, so it is troubling that they were more likely to be over-treated and less likely to have their medication regimens de-intensified,” said Dr. Sussman.
“By focusing on both overtreatment and under-treatment ends of the diabetes quality spectrum, we can best begin to improve the quality of diabetes care in all respects, ensuring that patients get needed care while avoiding unnecessary potential harm,” he concluded.