Despite guidelines, clinicians may treating older patients with diabetes too aggressively, according to a study published in Journal of the American Board of Family Medicine.
Tight glycemic control increases the risk for complications of diabetes, notably hypoglycemia, and this is particularly true for those who have had the disease for a long period of time and have comorbidities such as cardiovascular disease or cognitive impairment.
Among Medicare beneficiaries, the rates of hospitalization for hypoglycemia now exceed those for hyperglycemia; to help avoid this problem, both the American Diabetes Association and the American Geriatric Society recommend that glycemic targets be tailored to the individual patient and characteristics. These would include patient’s life expectancy, number and severity of comorbid chronic diseases, and cognitive and physical functioning.
The authors of the current study note that there are limited data on how clinicians use these recommendations when they are managing patients with diabetes. To get a sense for real-world clinical practice, primary care clinicians who most often manage older adults with diabetes were surveyed with common patient scenarios (336 responded). They were asked how they would manage the patient based on age, disease durations, and comorbidities, which were varied throughout the vignettes. Clinicians also specified whether they would intensify glycemic control by adding a second-line hypoglycemia medication.
Relatively younger patients with a low burden of comorbidity received appropriately high rates of treatment intensiﬁcation, but some patients did not receive care consistent with guidelines. For example, despite the recommendations for HbA1c targets of <8% for more complex patients, an 80-year-old woman with long-term diabetes, multiple comorbidities, and an HbA1c of 7.5% had a predicted probability of treatment intensiﬁcation of 35%.
Clinician type played a role in the decision for treatment intensification. Family practice physicians were signiﬁcantly less likely to intensify treatment compared with internal medicine physicians or nurse practitioners. More specifically, nurse practitioners were 14 percentage points more likely to intensify therapy vs family practice clinicians, whereas internal medicine physicians were 11 percentage points more likely to intensify therapy than those in family practice (P <.01).
“Our ﬁndings add to an important and growing body of evidence of missed opportunities to consider comorbid conditions indicating higher glycemic targets in order to avoid known harms,” conclude the authors.
McCreedy EM, Kane RL, Gollust SE, Shippee ND, Clark KD. Patient-centered guidelines for geriatric diabetes care: potential missed opportunities to avoid harm. J Am Board Fam Med. 2018;31(2):192-200.