Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries

Maciejewski, Matthew L.; Mi, Xiaojuan; Sussman, Jeremy B.; Greiner, Melissa A.; Curtis, Lesley H.; Ng, Judy; Haffer, Samuel C.; Kerr, Eve A.

doi:10.1007/s11606-017-4167-y

Cited by 39 publications

(61 citation statements)

References 34 publications

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“…This is one of the first national studies to evaluate potential overtreatment and deintensification of diabetes management in a subgroup of nursing home residents with LLE/AD. Although patterns of overtreatment and deintensification in diabetes were described previously in the literature, 14,16,17,41,42,[49][50][51] only one investigation examined the influence of life expectancy on diabetes management. 15 The proportion of residents who were overtreated in our sample (nearly half) aligns with previously reported estimates from large observational studies conducted in non-nursing home populations.…”

Section: Discussionmentioning

confidence: 99%

“…However, other studies of community-dwelling older adults with diabetes identified several other factors associated with increased likelihood for deintensification including more chronic conditions, greater frailty, and more outpatient visits. 41,42 One could argue that patients with these characteristics are common among older adults in the nursing home setting and that some may actually serve as drivers of institutionalization. Taken together, our findings indicate that in older CLC residents with LLE/AD, a population in which complex comorbidity and frailty are likely common, deintensification is not so much driven by individual clinical characteristics, but rather by a general concern for hypoglycemic adverse events that apply to all older adults.…”

Section: Discussionmentioning

confidence: 99%

“…We selected resident characteristics that may be associated with deintensification based on prior literature of diabetes overtreatment and deintensification, and behavioral theories applied to deprescribing. [14][15][16][17]41,42 Resident characteristics fell into five categories: sociodemographics, environment of care, diabetes-related factors, cardiovascular risk factors, and markers of poor prognosis. Most characteristics were operationalized using the MDS admission assessment, with additional information on comorbidities captured using VA/Medicare records from the year preceding admission, as well as BCMA data for medication covariates.…”

Section: Resident Characteristics Associated With Deintensificationmentioning

confidence: 99%

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Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes

Niznik

Hunnicutt

Zhao

et al. 2020

J American Geriatrics Society

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OBJECTIVES Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING VA CLCs. PARTICIPANTS A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7‐day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90‐day cumulative incidence of deintensification. RESULTS More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0‐7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50‐.66). Compared with non‐sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31‐1.88), except for basal insulin (aRR = .59; 95% CI = .52‐.66). The only resident factor associated with increased likelihood of deintensification was documented end‐of‐life status (aRR = 1.12; 95% CI = 1.01‐1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75‐.96), obesity (aRR = .88; 95% CI = .78‐.99), and peripheral vascular disease (aRR = .90; 95% CI = .81‐.99) were associated with decreased likelihood of deintensification. CONCLUSION Deintensification of treatment regimens occurred in less than one‐half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736–745, 2020

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Resident Characteristics Associated With Deintensificationmentioning

confidence: 99%

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Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes

Niznik

Hunnicutt

Zhao

et al. 2020

J American Geriatrics Society

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“…Glucose‐lowering medications to treat diabetes have been blamed for up to 25% of emergency hospitalizations in the USA to treat hypoglycemia . Diabetic treatments have also been implicated in cardiovascular events, cognitive impairment, fractures, and death . Aggressive hypertension treatments often cause hypotension with potentially severe side effects, including acute renal failure, hyponatremia, hypokalemia, and syncope .…”

Section: Overtreatment Is a Public Health Problemmentioning

confidence: 99%

“…Recent guidelines for treating diabetes and hypercholesterolemia already encourage setting individualized goals, but the challenge now, according to Huang, is to encourage physicians to adopt these guidelines. The American Geriatrics Society and the American Diabetes Association stress the increased risks of hypoglycemia and reduced benefits of aggressive treatment in older patients with mild forms of the disease and endorse higher glycemic targets . Likewise, the US Preventive Services Task Force's recent guidance on statin therapy recommended that adults aged 40–75 years without a history of CVD and 10‐year risk of a cardiovascular event of 10% or greater should use a low‐ to moderate‐dose statin to prevent CVD events.…”

Section: Addressing the Problemmentioning

confidence: 99%

Personalized medicine and proper dosage

Trasta¹

2018

EMBO Reports

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Patient Perceptions of Diabetes Guideline Frameworks for Individualizing Glycemic Targets

et al. 2019

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IMPORTANCE Diabetes guidelines recommend considering specific factors, such as diabetes duration and life expectancy, to individualize treatment in older adults. These individualized glycemic targets inform decisions on whether to intensify or deintensify medication treatment plans. How older adults with diabetes perceive these factors used to individualize glycemic targets is unknown.OBJECTIVES To examine how older adults perceive factors used in diabetes guidelines for individualizing glycemic targets. DESIGN, SETTING, AND PARTICIPANTSA cross-sectional national survey was conducted from December 13, 2018, to January 3, 2019, of a nationally representative, probability-based online survey panel (KnowledgePanel). A total of 1364 KnowledgePanel members who were 65 years or older and had type 2 diabetes were invited to participate in the survey; 836 (61.3%) responded, and 818 (60.0%) completed the survey. MAIN OUTCOMES AND MEASURESThe study randomized participants to 2 vignettes: one about adding and the other about removing diabetes medications from treatment plans. Participants rated the importance of 7 factors (diabetes duration, established diabetes complications, other health conditions, life expectancy, risk of adverse effects, cost, and treatment effort) in these treatment decisions using binary (yes/no) responses and the best-worst scaling method to quantify the factors' relative importance. All participants then answered questions on how different levels of each factor were associated with aggressiveness of diabetes treatment. RESULTSThe sample included 818 participants (mean [SD] age, 74.0 [6.8] years; 469 [53.7%] male; and 668 [67.7%] white). A total of 410 participants answered questions about adding medicine, whereas 408 participants answered questions about stopping medicine. Of the 7 factors to consider for adding a diabetes medication to the treatment plan, the number who deemed each factor important ranged from 197 (45.6%) to 263 (62.8%). In contrast, these same factors were considered important by only 29 (8.4%) to 146 (37.7%) of participants when deciding to stop use of a diabetes medication. In both decisions, participants perceived the risk of adverse effects as the most important factor (relative importance was 22.8 for adding a medicine and 25.0 for stopping a medicine on a ratio scale in which, for each decision, the relative importance of the 7 factors adds up to 100, with 0 indicating complete indifference and 100 complete priority). In contrast to current guideline recommendations, most participants believed that patients with longer disease duration (498 [60.1%]), more established complications (632 [75.6%]), and greater number of other health conditions (545 [67.5%]) should receive more aggressive diabetes treatment.CONCLUSIONS AND RELEVANCE Many older adults do not place high importance on factors recommended by guidelines to individualize diabetes treatment, especially when deciding to stop use of diabetes medications. Moreover, when considering treatment aggressiveness, many older ad...

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Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries

Abstract: Medicare recipients are more frequently overtreated than undertreated for diabetes. Medicare recipients who are overtreated for diabetes rarely have their regimens deintensified.

Cited by 39 publications

References 34 publications

Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes

Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes

Personalized medicine and proper dosage

Patient Perceptions of Diabetes Guideline Frameworks for Individualizing Glycemic Targets

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