Potential Overtreatment and Undertreatment of Diabetes in Different Patient Age Groups in Primary Care After the Introduction of Performance Measures

Abstract

OBJECTIVE To assess whether after the introduction of diabetes performance measures decreases in undertreatment correspond with increases in overtreatment for blood pressure (BP) and glycemic control in different patient age groups. RESEARCH DESIGN AND METHODS We conducted a cohort study using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database. General practices were included when data were available from 1 year before to at least 1 year after the introduction of diabetes performance measures. Included patients had a confirmed diagnosis of type 2 diabetes. Potential overtreatment was defined as prescribing maximum treatment or a treatment intensification to patients with a sustained low-risk factor level. Potential undertreatment was defined as a lack of treatment intensification in patients with a sustained high-risk factor level. Percentages of over- and undertreated patients at baseline were compared with those in subsequent years, and stratified analyses were performed for different patient age groups. RESULTS For BP, undertreatment significantly decreased from 61 to 57% in the first year after the introduction of performance measures. In patients >75 years of age, undertreatment decreased from 65 to ∼61%. Overtreatment was relatively stable (∼16%). For glycemic control, undertreatment significantly increased from 49 to 53%, and overtreatment remained relatively stable (∼7%). CONCLUSIONS The improvement of BP undertreatment after introduction of the performance measures did not correspond with an increase in overtreatment. The performance measures appeared to have little impact on improving glucose-regulating treatment. The trends did not differ among patient age groups.

Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review

“…Out of 7698 combined search results, 53 articles were identified that reported at least 1 measure of therapeutic inertia in the management of hyperglycaemia in individuals with type 2 diabetes . The main reasons for exclusion of publications other than duplicates and those covering irrelevant topics were that they reported non‐original research (eg, editorials, letters, comments and guidelines) or they were congress abstracts (Figure ).…”

“…Articles mainly reported data from cohort studies, using data from medical records or chart reviews, or from claims, clinical research or administrative databases. Four articles reported results from cross‐sectional studies, and the data were collected using provider questionnaires or surveys . A single publication reported results from a randomized clinical trial that evaluated the impact of physician education on the management of individuals with type 2 diabetes, and another provided results from a post hoc analysis of a randomized controlled trial …”

“…Patients were managed by primary care providers in 21 studies, by both primary care providers and secondary care specialists in 6 studies, and by secondary care specialists alone in 1 study . The healthcare providers responsible for patient care were not described in 25 studies .…”

“…The study by Kristensen et al included only patients managed with non‐pharmacological treatment . A single study considered 3 different treatment groups (OADs alone, insulin alone, and diet and exercise alone), and 2 others investigated patients treated with OADs and/or injectable drugs . Another group of studies included only patients who were not treated with insulin but did not describe their therapies in more detail (ie, glucagon‐like peptide‐1 [GLP‐1] receptor agonists were not explicitly excluded) .…”

“…There is no accepted measure to describe clinical or therapeutic inertia. For the purpose of this systematic review, studies were classified into 4 categories based on the measurement(s) used to quantify clinical/therapeutic inertia: (1) the mean or median length of time between at least one HbA1c measurement above a certain threshold and treatment intensification; (2) the proportion of patients with at least 1 HbA1c measurement above a certain threshold who received treatment intensification within a given time frame; (3) the glycaemic burden, defined as the length of time during which a patient had an HbA1c level above a certain threshold during a given period of time; and (4) all other measurements . HbA1c thresholds and the lengths of time to assess therapeutic inertia varied widely across the 53 studies, making comparisons difficult.…”